Utah Claims Dispute & Statutory Guide
Utah operates a mandatory No-Fault automobile insurance framework under Utah Code § 31A-22-306 et seq. Policies must carry a minimum of $3,000 in Personal Injury Protection (PIP) medical expense benefits. Medical provider reimbursement is governed by the Utah Insurance Department's Relative Value Study (RVS) fee schedule under Utah Admin. Code R590-102.
Statutory Framework & Jurisdiction
No-Fault (Mandatory PIP under Utah Code § 31A-22-307)
Utah law requires every automobile liability policy to provide minimum no-fault PIP coverage for accident-related medical, surgical, and hospital expenses regardless of fault. Injured claimants cannot file a tort lawsuit against an at-fault motorist for general damages (pain and suffering) unless they meet the statutory threshold under Utah Code § 31A-22-309 by incurring at least $3,000 in medical expenses or sustaining permanent impairment, permanent disfigurement, or disability.
PIP / MedPay Coverage & Medical Fee Rules
mandatory Medical Coverage
$3,000 statutory minimum per person for reasonable and necessary medical, surgical, nursing, and hospital expenses (Utah Code § 31A-22-307(1)(a))
work Loss And Funeral
Up to $250 per week for 52 weeks in lost wages, $20 per day for essential household services, and $1,500 for funeral costs
balance Billing Prohibition
Providers who accept direct assignment of PIP benefits may not balance bill the patient for amounts reduced pursuant to the department's fee schedule
assignment Of Benefits
Healthcare providers are paid directly upon submission of standard assignment of benefits documentation
Official Medical Fee Schedule & Reimbursement Standards
name
Utah Insurance Department Relative Value Study Fee Schedule (Utah Admin. Code R590-102)
rules
Reimbursement for medical, surgical, and diagnostic treatments rendered under PIP is capped at the maximum allowable rates established under the Utah Insurance Department's Relative Value Study (RVS) rule, adjusted by annual conversion factors for specific medical specialties.
cpt Basis
HCPCS/CPT codes matched to Utah Insurance Department RVS unit values and conversion factors
Preauthorization & Decision Point Review
requirement
Preauthorization is not required for emergency care or routine acute stabilization. Insurers may require treatment plans and peer review for non-emergency surgeries, advanced spinal injections, or long-term therapy programs.
independent Medical Examinations
Under Utah Code § 31A-22-305, insurers may require claimants to submit to an examination by a physician selected by the insurer when the medical necessity of continuing care is questioned.
Administrative Appeals & Dispute Mechanism
thirty Day Prompt Pay Rule
Under Utah Code § 31A-22-309(5), PIP benefits become overdue if not paid within 30 days after the insurer receives reasonable proof of the fact and amount of expenses. Overdue payments accrue interest at 1.5% per month (18% annually).
attorney Fees
If an insurer fails to pay benefits without reasonable cause, courts award the provider or claimant reasonable attorney fees incurred in collecting the overdue amount.
dispute Forum
Utah District Court or Justice Court (for claims within justice court monetary jurisdiction). Actions are filed as civil contract claims for recovery of no-fault benefits.
Critical Statutory & Dispute Deadlines
| Dispute Phase / Trigger Event | Statutory Timeline / Deadline |
|---|---|
| Notice of Accident / Loss | Notice to insurer as soon as practicable following the accident |
| Medical Bill Submission | Submission within standard claim filing timelines with itemized treatment records |
| Carrier 30-Day Pay Window | 30 calendar days from receipt of proof of loss (Utah Code § 31A-22-309(5)) |
| Medical Tort Threshold | $3,000 in medical expenses to maintain non-economic tort action (Utah Code § 31A-22-309) |
| Statute of Limitations | 3 years for PIP benefit claims (Utah Code § 78B-2-305); 4 years for tort actions (Utah Code § 78B-2-307) |
Required Evidentiary Filing Checklist
- ✓Utah PIP Claim Application (Notice of Injury Form)
- ✓Executed Assignment of Benefits (AOB) and patient authorization
- ✓Itemized CMS-1500 or UB-04 billing form with CPT/HCPCS and ICD-10 diagnostic coding
- ✓Contemporaneous medical records, physical therapy flowsheets, and diagnostic imaging reports
- ✓Explanation of Benefits (EOB) or written explanation of fee schedule reductions
Official Primary Sources & Legislative Authorities
Governing Regulatory Authorities
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