Title 20 — Insurance

In this article, unless the context otherwise requires: 1. "Adjudicate" means an insurer's decision to deny or pay a claim, in whole or in part, including the decision as to how much to pay. 2. "Clean claim" means a written or electronic claim for health care services or benefits…

A. A health care insurer shall adjudicate any clean claim from a contracted or noncontracted health care provider relating to health care insurance coverage within thirty days after the health care insurer receives the clean claim or within the time period specified by contract. …

(Eff. 7/1/26) Before a health care insurer may deny a claim that was submitted by a provider on the basis of medical necessity, the medical director shall individually review the denial. During each individual review, the medical director shall exercise independent medical judgme…

In this article, unless the context otherwise requires: 1. "Arbitration" means a dispute resolution process in which an impartial arbitrator determines the dollar amount a health care provider is entitled to receive for payment of a surprise out-of-network bill. 2. "Arbitrator" m…

This article does not apply to: 1. Health care services that are not covered by the enrollee's health plan. 2. Limited benefit coverage as defined in section 20-1137. 3. Charges for health care services that are subject to a direct payment agreement under section 32-3216 or 36-43…

A. A bill for a health care service that was provided in a network facility by a health care provider that is not a contracted provider must meet one of the following requirements to qualify as a surprise out-of-network bill: 1. The bill was for emergency services, including unde…

A. An enrollee who has received a surprise out-of-network bill and who disputes the amount of the bill may seek dispute resolution of the bill by filing a request for arbitration with the department not later than one year after the date of service noted in the surprise out-of-ne…

A. The department shall develop a simple, fair, efficient and cost-effective arbitration procedure for surprise out-of-network bill disputes and specify time frames, standards and other details of the arbitration proceeding, including procedures for scheduling and notifying the p…

To qualify as an arbitrator, a person shall have at least three years' experience in health care services claims and shall comply with any other qualifications established by the department.

A. The department in conjunction with the appropriate health care boards shall prescribe the notice outlining an enrollee's rights to dispute surprise out-of-network bills under this article. B. Health insurers shall include the notice prescribed pursuant to subsection A of this …

A. On or before December 31, 2019 and each December 31 thereafter, the department shall report on the resolution of disputed surprise out-of-network bills. The report shall include: 1. The total number of inquiries regarding dispute resolution of surprise out-of-network bills. 2.…

An enrollee who is aggrieved by an arbitration decision regarding a disputed surprise out-of-network bill may file a civil action in superior court not later than one year after the date of the disputed decision to obtain appropriate relief with respect to the same surprise out-o…