Utah provides comprehensive surprise billing protections through both state law and the federal No Surprises Act. These overlapping protections ensure patients pay only in-network cost-sharing for covered emergency and scheduled services.
Utah Code §31A-22-635 State Protection (Effective January 1, 2021)
Utah Code §31A-22-635 predates the federal No Surprises Act and provides state-level surprise billing protections. The federal No Surprises Act, effective January 1, 2022, applies concurrently, and the greater protection applies when rules differ.
Federal No Surprises Act (January 1, 2022)
The federal No Surprises Act applies to all ERISA and state-regulated health plans in Utah. It prohibits balance billing for emergency services and scheduled non-emergency services at in-network facilities.
Emergency Care In-Network Cost-Sharing Only
For emergency services at any hospital or emergency facility, patients pay only in-network cost-sharing amounts. Out-of-network providers cannot balance bill the patient for amounts exceeding in-network cost-sharing.
Scheduled Services at In-Network Facilities: 72-Hour Consent Requirement
When a patient schedules a non-emergency service at an in-network facility but receives care from an out-of-network provider, the provider must provide 72-hour advance written consent before billing above in-network rates. Without this consent, the patient owes only in-network cost-sharing.
Federal Independent Dispute Resolution (IDR) Process
Utah uses the federal IDR process for payment disputes between providers and health plans. Either party can initiate IDR if they disagree on appropriate payment, and an independent reviewer determines the rate.
Good Faith Estimate Requirement
Health plans must provide Good Faith Estimates before scheduled services so patients understand expected out-of-pocket costs upfront.
How to Invoke Surprise Billing Protections in Utah
- Identify the unexpected OON charge on the Explanation of Benefits (EOB).
- Notify the health plan citing Utah Code §31A-22-635 and federal NSA in writing.
- Request an in-network rate adjustment with supporting documentation of the bill.
- File a UID complaint (state plans) or CMS complaint (ERISA plans) if unresolved within 30 days.
Altair identifies surprise billing violations and helps you enforce Utah patient protections.
Frequently Asked Questions
Does Utah have a state surprise billing law that predates the federal NSA?
Yes, Utah Code §31A-22-635 was effective January 1, 2021, predating the federal No Surprises Act by one year. Both laws now apply concurrently in Utah.
How does advance consent work in Utah for elective OON services?
For scheduled non-emergency services at in-network facilities, out-of-network providers must provide 72-hour advance written consent before billing above in-network rates. The patient must sign to authorize higher billing.
What happens when the 72-hour consent requirement is violated?
If an out-of-network provider bills above in-network rates without 72-hour advance written consent, the patient owes only in-network cost-sharing. The provider must bill the plan for the remainder.
Related Utah Insurance Topics
- Utah Balance Billing Protections
- Utah Timely Filing Requirements
- Utah Prior Authorization Rules
- All State Billing Laws
- Federal No Surprises Act