DAR File No. 39904

Insurance, Administration

Rule R590-267

Personal Injury Protection Relative Value Study Rule

Notice of Proposed Rule

(Amendment)

DAR File No.: 39904
Filed: 10/30/2015 04:17:45 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment updates the rule to add conversion factors and publications for use in 2016.

Summary of the rule or change:

The change adds conversion factors and publications for physicians to use when determining the reasonable value of services provided to patients on or after 01/01/2016. It also gives an end date of 12/31/2015 for the previously included conversion factors.

State statutory or constitutional authorization for this rule:

• Subsection 31A-22-307(2)
• Subsection 31A-2-201(3)

This rule or change incorporates by reference the following material:

• Adds Relative Values for Physicians, published by Optum360, 2015
• Adds Relative Values for Dentists, published by Optum360, 2015

Anticipated cost or savings to:

the state budget:

The department will be required to purchase two hard copies of the incorporated by reference RVD 2015 at $260 each and two copies of the RVP 2015 at $330 each. One copy will be maintained by the department and one copy will be maintained by the Division of Administrative Rules per rulemaking requirements.

local governments:

There will be no cost or savings to local government. The rule covers method by which providers determine the reasonable value of services they provide to consumers.

small businesses:

Medical, dental, and chiropractic offices that provide services for individuals insured in auto accidents will need to purchase individually or as a group the RVD 2015 or RVP 2015 publication incorporated by reference in the rule. The cost of the RVD 2015 will be $260 for a hard copy. The cost of the RVP 2015 will be $330 for a hard copy. By using the publication with the conversion factors in the rule, they will be able to determine the reasonable charges for services they provide to those injured in automobile accidents.

persons other than small businesses, businesses, or local governmental entities:

Auto insurers, or those they contract with to service their claims, may purchase the RVD 2015 or RVP 2015 publication incorporated by reference in the rule. The cost of the RVD 2015 will be $260 for a hard copy. The cost of the RVP 2015 will be $330 for a hard copy. By using the publication with the conversion factors in the rule, they will be able to determine the reasonable charges of medical and dental services they are required to reimburse providers for treatment under personal injury protection coverage in Utah.

Compliance costs for affected persons:

Auto insurers, or those they contract with to service their claims, and health care providers may purchase the RVD 2015 or RVP 2015 publication incorporated by reference in the rule. The cost of the RVD 2015 will be $260 for a hard copy. The cost of the RVP 2015 will be $330 for a hard copy.

Comments by the department head on the fiscal impact the rule may have on businesses:

Certain businesses will need to purchase copies of either the RVD 2015 or RVP 2015 from Optum360 to comply with the rule. These businesses will then be able to determine the reasonable charges of medical and dental services they are required to reimburse providers for treatment under personal injury protection coverage in Utah.

Todd E. Kiser, Commissioner

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Insurance
Administration
Room 3110 STATE OFFICE BLDG
450 N MAIN ST
SALT LAKE CITY, UT 84114-1201

Direct questions regarding this rule to:

• Steve Gooch at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at sgooch@utah.gov

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:

12/15/2015

This rule may become effective on:

12/22/2015

Authorized by:

Steve Gooch, Information Specialist

R590. Insurance, Administration.

R590-267. Personal Injury Protection Relative Value Study Rule.

R590-267-1. Authority.

This rule is promulgated by the insurance commissioner pursuant to S ubsections 31A-2-201(3)[,] and 31A-22-307(2).

 

R590-267-2. Purpose.

(1) The purpose of this rule is to establish a reasonable value of services and accommodations for the diagnosis, care, recovery, or rehabilitation of an injured person under automobile personal injury protection coverage as described in Subsection 31A-22-307(1)(a).

(2) As required by Subsection 31A-22-307(2), the reasonable value is based on the 75th percentile of medical, dental, and chiropractic charges, as they presently exist in the most populous county in this State.

 

R590-267-3. Scope.

This rule applies to services and accommodations provided:

(1) [provided ]under automobile personal injury protection coverage as described in Subsection 31A-22-307(1)(a); and

(2) [provided ]on or after January 1, 2014.

 

R590-267-4. Definitions.

(1) As used in this rule "Conversion Factor" means a multiplier used to convert the relative value unit or units of a service or a procedure to a reimbursement rate.

(2) As used in this rule "RVD 2015" means 2015 Edition of the Relative Values for Dentists published by Optum360, 2525 Lake Park Blvd., Salt Lake City, UT 84120; phone: (800) 464-3649; email: customerassistance@optum.com; website: www.optumcoding.com.

(3) As used in this rule "RVD 2013" means 2013 Edition of the Relative Values for Dentists published by Relative Values Studies, Inc., 12301 N. Grant St., Suite 230, Thornton, CO, 80241; phone: (866) 310-7874; email: info@rvsdata.com; website: www.rvsdata.com.

([3]4) As used in this rule "RVP 2015" means 2015 Edition of the Relative Values for Physicians published by Optum360, 2525 Lake Park Blvd., Salt Lake City, UT 84120; phone: (800) 464-3649; email: customerassistance@optum.com; website: www.optumcoding.com.

(5) As used in this rule "RVP 2013" means 2013 Edition of the Relative Values for Physicians published by Optum[Insight]360, 2525 Lake Park Blvd., Salt Lake City, UT 84120; phone: (800) 464-3649; email: customerassistance@optum.com; website: www.optum coding.com.

([4]6) As used in this rule "Relative Value Unit" means a numerical value assigned to a medical or dental procedure as published in RVP and RVD respectively.

([5]7) The publications identified in Subsections R590-267-4[.](2)[and], (3), (4), and (5) are hereby incorporated by reference within this rule.

 

R590-267-5. Conversion Factors.

(1) (a) The following conversion factors shall be used with RVP 2015 to determine the reasonable value of medical services or accommodations provided on or after January 1, 2016:

(i) anesthesia, 97.13;

(ii) surgery, 200.00;

(iii) radiology, 35.84;

(iv) pathology, 24.29;

(v) medicine, 11.67;

(vi) evaluation and management, 13.16.

(b) The conversion factor used with RVD 2015 to determine the reasonable value of dental services or accommodations provided on or after January 1, 2016 shall be 60.00.

(2)(a) The following conversion factors shall be used with RVP 2013 to determine the reasonable value of medical services or accommodations provided from January 1, 2014 through December 31, 2015:

([a]i) anesthesia, 91.57;

([b]ii) surgery, 180.00;

([c]iii) radiology, 35.18;

([d]iv) pathology, 23.85;

([e]v) medicine, 10.87;

([f]vi) evaluation and management, 11.85.

([2]b) The conversion factor used with RVD 2013 to determine the reasonable value of dental services or accommodations provided from January 1, 2014 through December 31, 2015 shall be 55.00.

 

R590-267-6. Fee Schedule.

The reasonable value of any service or accommodation shall be calculated by multiplying the relative value unit assigned to the service or accommodation by the applicable conversion factor prescribed in R590-267-5.

 

R590-267-7. Penalties.

A person found to be in violation of this rule shall be subject to penalties as provided under Section 31A-2-308.

 

R590-267-8. [Enforcement Date.

The commissioner will begin enforcing the provisions of this rule on January 1, 2014.

 

R590-267-9. ]Severability.

If any provision of this rule or its application to any person or situation is held to be invalid, that invalidity shall not affect any other provision or application of this rule which can be given effect without the invalid provision or application, and to this end the provisions of this rule are declared to be severable.

 

KEY: relative value study

Date of Enactment or Last Substantive Amendment: [November 18, 2013]2015

Authorizing, and Implemented or Interpreted Law: 31A-2-201(3); 31A-22-307(2)