File No. 34894
This rule was published in the June 15, 2011, issue (Vol. 2011, No. 12) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Outpatient Hospital Services: Payment of Triage Fee
Notice of Proposed Rule
DAR File No.: 34894
Filed: 06/01/2011 12:38:35 PM
Purpose of the rule or reason for the change:
This rule states authority and purpose, outlines triage policies, and defines terms in the rule text. It also specifies service coverage, standards of care, prior authorization requirements, and reimbursement for services. The Department needs to repeal this rule based on internal review that shows that the Department no longer uses the policies spelled out in the text.
Summary of the rule or change:
This rule is repealed in its entirety.
State statutory or constitutional authorization for this rule:
- Section 26-18-3
- Section 26-1-5
Anticipated cost or savings to:
the state budget:
There is no impact to the state budget because the Department no longer uses the policies set forth in this rule.
There is no impact to local governments because they do not fund or provide outpatient hospital services under the Medicaid program.
There is no impact to small businesses because the Department no longer uses the policies set forth in this rule.
persons other than small businesses, businesses, or local governmental entities:
There is no impact to Medicaid clients and to Medicaid providers because the Department no longer uses the policies set forth in this rule.
Compliance costs for affected persons:
There are no compliance costs to a single Medicaid client or to a Medicaid provider because the Department no longer uses the policies set forth in this rule.
Comments by the department head on the fiscal impact the rule may have on businesses:
This rule specifies an obsolete practice. Repeal should have no fiscal impact.
W. David Patton, PhD, Executive Director
The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:Health
Health Care Financing, Coverage and Reimbursement Policy
288 N 1460 W
SALT LAKE CITY, UT 84116-3231
Direct questions regarding this rule to:
- Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at firstname.lastname@example.org
Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:
This rule may become effective on:
David Patton, Executive Director
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-4A. Outpatient Hospital Services: Payment of Triage
R414-4A-1. Policy Statement. (1) Primary medical care is best delivered by a primary
care physician who, through the physician-patient therapeutic
relationship, can deliver or arrange the appropriate mix of
medical and other services that the patient needs. Primary care
physicians are skilled at early detection of disease and
delivering prompt treatment, and in promoting health and
(2) Hospital emergency rooms are not the appropriate
place for patients to receive primary or routine medical
R414-4A-2. Authority and Purpose. (1) The Utah Department of Health is the Single State
Agency. The Division of Health Care Financing has the authority
to define the scope of outpatient hospital services to be
delivered under the Utah State Plan for Medicaid.
(2) The purpose of paying a triage fee is to reimburse
the hospitals for the emergency room physician's service of
assessing the medical status of a patient. If a patient's
medical needs are determined by the emergency room physicians to
be routine, that is, not of an emergency or urgent nature, the
patient will be referred to his primary care physician for the
treatment of his routine care needs and will not be treated in
the emergency room.
(3) It is cost-effective for clients to seek primary and
routine medical care through their primary medical provider
rather than seeking these services through hospital emergency
R414-4A-3. Definitions. (1) "Emergency" means a condition for which a
delay in treatment may result in death or permanent impairment of
(2) "Primary care physician" means a
practitioner whose practice is the field of general practice,
family practice, pediatrics, internal medicine,
obstetrics/gynecology, osteopathy, or nurse midwifery.
(3) "Primary medical care" means services to
diagnose and treat illness and injury as well as preventive
health care services. Primary and preventive health care services
promote early identification and treatment of health problems,
which can help to reduce unnecessary complications of illness or
injury and maintain or improve overall health status.
(4) "Triage" means the sorting and
classification of patients, to determine priority of need for
treatment and proper place of treatment.
(5) "Urgent" means a condition not likely to
cause death or lasting harm, but for which treatment should not
wait for a normally scheduled appointment (e.g., suturing minor
cuts, setting simple broken bones, and treating conditions
characterized by abnormally high temperatures).
R414-4A-4. Service Coverage. (1) Triage service includes services such as: assessment
and diagnosis of a patient's condition and determination of a
proper place for treatment.
(2) Triage service may only be performed by a licensed
R414-4A-5. Standards of Care. It is a decision of the emergency room physician whether
medical care is classified as routine, urgent, or is an
R414-4A-6. Prior Authorization. None required.
R414-4A-7. Reimbursement for Services. (1) Payment for triage services is made on a revenue code
(2) When a triage service is billed, no other medical
care services will be paid by Medicaid for that date of service,
to the same provider for the same triage encounter.
(3) Rates are based on an encounter unit of
(4) The Division of Health Care Financing will not pay a
claim for triage services for which another payer is liable, nor
for services for which no payment liability is incurred.
Date of Enactment or Last Substantive Amendment: 1993
Notice of Continuation: January 26, 2007
Authorizing, and Implemented or Interpreted Law: 26-1-5;
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2011/b20110615.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at email@example.com.