Colo. Rev. Stat. § 10-16-111, Annual statements and reports

(1) Nonprofit hospital, medical-surgical, and health service corporations. (a) All corporations subject to the provisions of this part 1 and part 3 of this article doing business in this state on July 1, 1967, or which may thereafter do business in this state, shall make and file annually with the commissioner, on or before the first day of March of each year, a statement under oath upon a form prescribed by the commissioner stating the amount of all membership dues or subscriber fees collected in this state or from residents thereof by the corporation making such statement during the year ending the last day of December next preceding; the amounts actually paid during such year for hospital, medical-surgical, and other health services for the subscribers or members of the corporation, and the amounts placed in established reserves for cases billed but not yet paid, unreported and unbilled cases, retroactive cost adjustments, membership dues or fees paid in advance but not yet earned, and all other liabilities and obligations required of domestic insurers which are consistent with the responsibilities of such corporations. The annual statement made to the commissioner pursuant to this subsection (1) shall at least include the substance of that which is required by what is known as the convention blank form for hospital, medical, and dental service or indemnity corporations adopted from year to year by the national association of insurance commissioners, including any instructions, procedures, and guidelines not in conflict with any provision of this title for completing the convention blank form.

(b) In preparing the statements required by paragraph (a) of this subsection (1), all insurance companies shall follow the instructions, procedures, and guidelines of the national association of insurance commissioners. If the initial application of any such instruction, procedure, or guideline would cause a reduction in the total capital and surplus of a domestic insurer of ten percent or more or would cause the capital and surplus of a domestic insurer to fall to or below the company action level as defined by the commissioner by rule, such insurer may, within thirty days after the effective date of such instruction, procedure, or guideline, file with the commissioner a request to phase in the effect of the instruction, procedure, or guideline over a period not to exceed three years or a time period approved by the commissioner.

(c) Any request made pursuant to paragraph (b) of this subsection (1) shall include a complete analysis, in a form prescribed by the commissioner, of the impact upon the insurer making the request that is expected to result from application of the subject instruction, procedure, or guideline and, if a phase-in is requested, a description of the insurer's plan for the phase-in period. The commissioner shall not deny a request for a phase-in except upon notice and the opportunity for a hearing as provided in section 24-4-105, C.R.S.

(d) Any request for a hearing made pursuant to paragraph (c) of this subsection (1) shall include a description of the basis on which relief is sought. Upon receiving such a request, the commissioner shall postpone the effective date of the subject instruction, procedure, or guideline pending the conclusion of the hearing and the taking of final agency action thereon. The hearing shall commence within sixty days after the commissioner receives the request and shall be conducted in accordance with section 24-4-105, C.R.S.

(2) Health maintenance organizations. (a) Every health maintenance organization shall annually, on or before March 1, file a report verified by at least two principal officers with the commissioner covering the preceding calendar year.

(b) The report must be on forms prescribed by the commissioner and shall include:

(I) A financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding year certified by an independent public accountant;

(II) Any material changes in the information submitted pursuant to section 10-16-401 (3);

(III) The number of persons enrolled during the year, the number of enrollees as of the end of the year, and the number of enrollments terminated during the year;

(IV) A summary of information compiled pursuant to section 10-16-402 (1)(b)(III) in such form as required by the commissioner;

(V) Such other information relating to the performance of the health maintenance organization as is necessary to enable the commissioner to carry out the commissioner's duties under this part 1 and part 4 of this article.

(e) Each health maintenance organization shall report to the commissioner within five days of receipt or determination of a noncompliance order issued by the United States department of health and human services. Each health maintenance organization shall report to the commissioner within five days of receipt of determination by the United States department of health and human services or the health maintenance organization or a creditor or guarantor as to repayment schedule of loans or modification of financial commitments. The report shall include any determination for the ensuing twelve-month period. Upon providing such report, the health maintenance organization shall submit a revised financial statement recognizing the appropriate amounts as a direct liability.

(3) Prepaid dental care plan organizations. (a) Every prepaid dental care plan organization subject to this part 1 and part 5 of this article shall file with the commissioner annually, on or before March 1, a report verified by at least two principal officers covering the preceding calendar year.

(b) Such report shall be on forms prescribed by the commissioner and shall include:

(I) A financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding year certified by an independent public accountant;

(II) Any material changes in the information submitted pursuant to section 10-16-503 (1);

(III) The number of persons enrolled during the year, the number of enrollees as of the end of the year, and the number of enrollments terminated during the year;

(IV) Statistics relating to the cost of its operations, the pattern of utilization of its services, and the availability and accessibility of its services;

(V) Such other information relating to the performance of the organization as is necessary to enable the commissioner to carry out the commissioner's duties under this part 1 and part 5 of this article.

(4) Carriers. (a) On or before June 1 of each year, a carrier doing business in this state that satisfies qualifications as determined by rule of the commissioner shall submit to the commissioner, where applicable, the following cost information for the previous calendar year:

(I) Medical trend itemized by medical provider price increases, utilization changes, medical cost shifting, and new medical procedures and technology;

(II) Medical trend itemized by pharmaceutical price increases, utilization changes, cost shifting, and the introductions of new brand and generic drugs;

(III) Dividends paid;

(IV) Executive salaries, stock options, or bonuses;

(V) Insurance producer commissions;

(VI) Payments to legal counsel;

(VII) Provision for profit and contingencies;

(VIII) Administrative expenditures with breakdowns for advertising or marketing expenditures, paid lobbying expenditures, and staff salaries;

(IX) Expenditures for disease or case management programs or patient education and other cost containment or quality improvement expenses;

(X) Charitable contributions;

(XI) Losses on investments or investment income;

(XII) Reserves on hand;

(XIII) The amount of surplus and the amount of surplus relative to the carrier's risk-based capital requirement;

(XIV) Taxes itemized by category;

(XV) Administrative ratio;

(XVI) Actual benefits ratio;

(XVII) The number of lives insured under each benefit plan the carrier offers to small employers;

(XVIII) The cost of providing or arranging health-care services; and

(XIX) A list of each intermediary with whom the carrier has a contractual relationship.

(a.5) Repealed.

(b) A carrier licensed in multiple jurisdictions may satisfy the requirements of paragraph (a) of this subsection (4) by filing the Colorado allocated portion of national data if the actual data is not otherwise available.

(c) The commissioner shall aggregate the data submitted pursuant to paragraph (a) of this subsection (4) for all carriers and publish the information on the division's website. Notwithstanding section 24-1-136 (11)(a)(I), the commissioner shall submit a report annually to the general assembly that analyzes the cost of health care and the factors that drive the cost of health care on an individual and group basis in this state.

(d) Notwithstanding section 24-1-136 (11)(a)(I), the commissioner shall report annually to the general assembly regarding financial information on carriers that includes, but is not limited to, benefits ratios, rate increases, and the reasons or data tracked for cost increases, as applicable for health insurance provided pursuant to this article.

(e) When promulgating rules pursuant to paragraph (a) of this subsection (4), the commissioner shall ensure that at least ninety-two percent of the market share reports cost information.

Source: L. 92: Entire article R&RE, p. 1656, � 1, effective July 1; (1) amended, p. 1592, � 113, effective July 1. L. 94: (1) amended, p. 595, � 1, effective April 7. L. 97: (1) amended, p. 92, � 3, effective March 24. L. 99: (2)(c) and (2)(d) repealed, p. 85, � 7, effective July 1. L. 2008: (4) added, p. 2255, � 9, effective July 1. L. 2011: (4)(a.5) added, (SB 11-128), ch. 133, p. 469, � 4, effective April 29. L. 2013: IP(4)(a), (4)(a)(XVII), and (4)(a)(XVIII) amended and (4)(a)(XIX) and (4)(e) added, (HB 13-1223), ch. 145, p. 468, � 1, effective April 26. L. 2017: (2)(a), IP(2)(b), and (2)(b)(IV) amended, (SB 17-249), ch. 283, p.1547, � 12, effective June 1; (4)(c) and (4)(d) amended, (SB 17-044), ch. 4, p. 7, � 3, effective August 9.

Editor's note: (1) The provisions of this section are similar to provisions of several former sections as they existed prior to 1992. For a detailed comparison, see the comparative tables located in the back of the index.

(2) Subsection (4)(a.5)(II) provided for the repeal of subsection (4)(a.5), effective January 1, 2014. (See L. 2011, p. 469.)

Cross references: (1) In 2008, subsection (4) was enacted by the Fair Accountable Insurance Rates Act. For the short title and legislative declaration, see sections 1 and 2 of chapter 439, Session Laws of Colorado 2008.

(2) For the legislative declaration in the 2011 act adding subsection (4)(a.5), see section 1 of chapter 133, Session Laws of Colorado 2011.

10-16-112. Private utilization review - health-care coverage entity responsibility - definitions. (1) As used in this section, unless the context otherwise requires:

(a) Private utilization review organization means an entity, other than a hospital or public reviewer following federal guidelines, that conducts utilization review or reviews and makes determinations on prior authorization requests for health-care services as described in section 10-16-112.5. This definition shall not apply to any independent medical examination provided for in any policy of insurance.

(b) Utilization review means an evaluation of the necessity, appropriateness, and efficiency of the use of health-care services, procedures, and facilities, but does not include any independent medical examination provided for in any policy of insurance.

(2) Any private utilization review organization providing services to an insurance carrier, nonprofit hospital and health-care service corporation, or health maintenance organization regulated pursuant to the provisions of this article is the direct representative of the insurance carrier, nonprofit hospital and health-care service corporation, or health maintenance organization. Any insurance carrier, nonprofit hospital and health-care service corporation, or health maintenance organization is responsible for the actions of any private utilization review organization acting within the scope of any contract and on its behalf within the scope of any contract which result in any violation of this title or any rules or regulations promulgated by the commissioner.

Source: L. 93: Entire section added, p. 494, � 2, effective April 26. L. 2019: (1)(a) amended, (HB 19-1211), ch. 165, p. 1910, � 3, effective August 2.

Cross references: For the legislative declaration in HB 19-1211, see section 1 of chapter 165, Session Laws of Colorado 2019.

10-16-112.5. Prior authorization for health-care services - disclosures and notice - determination deadlines - criteria - limits and exceptions - enforcement - definitions - rules. (1) Applicability. (a) On or after January 1, 2020, a carrier or, if a carrier contracts with a private utilization review organization to perform prior authorization for health-care services, the organization shall use the prior authorization process and comply with the requirements specified in this section. Except as otherwise specified in this section, this section applies to prior authorization requests for health-care services, excluding requests for drug benefits pursuant to section 10-16-124.5.

(b) This section does not apply to:

(I) A health maintenance organization with respect to managed care plans that provide a majority of covered professional services through a single contracted medical group;

(II) A nonprofit health maintenance organization operated by or under the control of the Denver health and hospital authority created by article 29 of title 25 or any subsidiary of the authority; or

(III) Carriers, organizations, and medical benefits subject to the Workers' Compensation Act of Colorado, articles 40 to 47 of title 8.

(2) Disclosure of requirements - notice of changes - rules. (a) [Editor's note: For the applicability of this subsection (2)(a) on or after January 1, 2026, see the editor's note following this section.]

(I) A carrier shall post current prior authorization requirements and restrictions, including written, clinical criteria, on the carrier's public-facing website in a readily accessible, standardized, searchable format. The prior authorization requirements must be described in detail and in clear and easily understandable language.

(II) If a carrier contracts with a private utilization review organization to perform prior authorization for health-care services, the organization shall provide its prior authorization requirements and restrictions, as required by this subsection (2), to the carrier with which the organization contracted, and that carrier shall post the organization's prior authorization requirements and restrictions on its public-facing website in the manner required by subsection (2)(a)(I) of this section.

(b) If a carrier or organization intends to implement a new prior authorization requirement or restriction or to amend an existing requirement or restriction, the carrier or organization shall:

(I) Notify any participating providers of the new or amended requirement or restriction in the manner and within the time specified in section 25-37-102 (9)(c) or 25-37-104 (1), as applicable; and

(II) Update the prior authorization information posted on the carrier's website pursuant to subsection (2)(a) of this section to reflect the new or amended prior authorization requirement or restriction before implementing the new or amended requirement or restriction.

(c) [Editor's note: For the applicability of this subsection (2)(c) on or after January 1, 2026, see the editor's note following this section.]

(I) A carrier shall post, on a public-facing portion of its website, data regarding approvals and denials of prior authorization requests, including requests for drug benefits pursuant to section 10-16-124.5, in a readily accessible, standardized, searchable format and that include the following:

(A) The total number of prior authorization requests received in the immediately preceding calendar year in each of the following categories of services: Medical procedures, diagnostic tests and diagnostic images, prescription drugs, and all other categories of health-care services or drug benefits for which a prior authorization request was received;

(B) The total number of prior authorization requests that were approved in each of the categories specified in subsection (2)(c)(I)(A) of this section;

(B.5) The total number of prior authorization requests for which an adverse determination was issued and the service was denied in each of the categories specified in subsection (2)(c)(I)(A) of this section;

(C) The reason for the denial in each of the categories specified in subsection (2)(c)(I)(A) of this section, with the denial reasons sorted by categories defined by rule; and

(D) In each of the categories specified in subsection (2)(c)(I)(A) of this section, the total number of adverse determinations that were appealed and whether the determination was upheld or reversed on appeal.

(II) An organization or PBM that provides prior authorization for a carrier shall provide the data specified in subsection (2)(c)(I) of this section to the carrier with which the organization or PBM contracted, and the carrier shall post the organization's or PBM's data on its public-facing website in the manner required by subsection (2)(c)(I) of this section.

(III) Carriers and organizations shall use the data specified in this subsection (2)(c) to refine and improve their utilization management programs. Carriers and organizations shall review the list of medical procedures, diagnostic tests and diagnostic images, prescription drugs, and other health-care services for which the carrier or organization requires prior authorization at least annually and shall eliminate the prior authorization requirements for those procedures, diagnostic tests and diagnostic images, prescription drugs, or other health-care services for which prior authorization neither promotes health-care quality or equity nor substantially reduces health-care spending. Each carrier and organization shall annually attest to the commissioner that it has completed the review required by this subsection (2)(c)(III) and has eliminated prior authorization requirements consistent with the requirements of this subsection (2)(c)(III).

(IV) A carrier shall post, on a public-facing portion of its website, in a readily accessible, standardized, searchable format, data on the number of exemptions from prior authorization requirements or alternatives to prior authorization requirements provided pursuant to a program adopted by the carrier, organization, or PBM pursuant to subsection (4)(b)(II) of this section or section 10-16-124.5 (5.5), as applicable. The carrier shall include the following data:

(A) The number of providers offered an exemption or alternative program, including their specialty areas;

(B) The number and categorized types of exemptions or alternative programs offered to providers; and

(C) The prescription drug, diagnostic test, procedure, or other health-care service for which an exemption or alternative program was offered.

(V) The commissioner shall adopt rules to:

(A) Implement subsections (2)(c)(I) and (2)(c)(IV) of this section to ensure that the data fields required to be posted pursuant to subsections (2)(c)(I) and (2)(c)(IV) of this section are presented consistently by carriers; and

(B) Define categories of prior authorization request denials for purposes of subsection (2)(c)(I)(C) of this section.

(3) Nonurgent and urgent health-care services - timely determination - notice of determination - deemed approved. (a) Except as provided in subsection (3)(b) of this section, a prior authorization request is deemed granted if a carrier or organization fails to:

(I) [Editor's note: For the applicability of this subsection (3)(a)(I) on or after January 1, 2026, see the editor's note following this section.]

(A) Notify the provider and covered person, within five business days after receipt of the request, that the request is approved, denied, or incomplete and indicate: If denied, what relevant alternative services or treatments may be a covered benefit or are required before approval of the denied service or treatment or, if incomplete, the specific additional information, consistent with criteria posted pursuant to subsection (2)(a) of this section, that is required to process the request; or

(B) Notify the provider and covered person, within five business days after receiving the additional information required by the carrier or organization pursuant to subsection (3)(a)(I)(A) of this section, that the request is approved or denied and, if denied, indicate what relevant alternative services or treatments may be a covered benefit or are required before approval of the denied service or treatment; and

(II) For a prior authorization request for urgent health-care services:

(A) Notify the provider and covered person, within two business days but not longer than seventy-two hours after receipt of the request, that the request is approved, denied, or incomplete and, if incomplete, indicate the specific additional information, consistent with criteria posted pursuant to subsection (2)(a) of this section, that is required to process the request; or

(B) Notify the provider and covered person, within two business days but not longer than seventy-two hours after receiving the additional information required by the carrier or organization pursuant to subsection (3)(a)(II)(A) of this section, that the request is approved or denied.

(b) If a carrier or organization notifies the provider and covered person pursuant to subsection (3)(a)(I)(A) or (3)(a)(II)(A) of this section that a prior authorization request is incomplete and that additional information is required, the provider shall submit the additional information within two business days after receipt of the notice from the carrier or organization. If the provider fails to submit the required additional information within two business days after receipt of the notice, the request is not deemed granted pursuant to subsection (3)(a) of this section. After receipt of the required additional information, the carrier or organization shall respond to the prior authorization request in accordance with subsection (3)(a)(I)(B) of this section or, for a prior authorization request for urgent health-care services, subsection (3)(a)(II)(B) of this section.

(c) (I) When notifying the provider of the determination on a prior authorization request, the carrier or organization shall provide a unique prior authorization number attributable to that request and the particular health-care service that is the subject of the request.

(II) [Editor's note: For the applicability of this subsection (3)(c)(II) on or after January 1, 2026, see the editor's note following this section.] If the carrier or organization denies a prior authorization request based on a ground specified in section 10-16-113 (3)(a), the notification is subject to the requirements of section 10-16-113 (3)(a) and commissioner rules adopted pursuant to that section and must:

(A) Include information concerning whether the carrier or organization requires an alternative treatment, test, procedure, or medication and what alternative services or treatments would be approved as a covered benefit under the health benefit plan; or

(B) In the case of the denial of a prior authorization request for a prescription drug, specify which prescription drugs and dosages in the same class as the prescription drug for which the prior authorization request was denied are covered prescription drugs under the health benefit plan.

(III) [Editor's note: For the applicability of this subsection (3)(c)(III) on or after January 1, 2026, see the editor's note following this section.] A carrier's, organization's, or pharmacy benefit manager's compliance with subsection (3)(c)(II) of this section does not constitute the practice of medicine.

(d) This subsection (3) does not apply to prior authorization requests for drug benefits that are subject to section 10-16-124.5; except that subsection (3)(c)(II) of this section applies to prior authorization requests for drug benefits.

(3.5) [Editor's note: For the applicability of this subsection (3.5) on or after January 1, 2026, see the editor's note following this section.]

(a) Starting January 1, 2027, a carrier or organization shall have, maintain, and use a prior authorization application programming interface that automates the prior authorization process to enable a provider to:

(I) Determine whether prior authorization is required for a health-care service;

(II) Identify prior authorization information and documentation requirements; and

(III) Facilitate the exchange of prior authorization requests and determinations from the provider's electronic health records or practice management systems through secure electronic transmission.

(b) A carrier's or organization's application programming interface must meet the most recent standards and implementation specifications adopted by the secretary of the United States department of health and human services as specified in 45 CFR 170.215 (a).

(c) If a provider submits a prior authorization request through the carrier's or organization's application programming interface, the carrier or organization shall accept and respond to the request through the interface.

(4) Criteria, limits, and exceptions - program. (a) Carriers and organizations shall:

(I) Use prior authorization criteria that are current, clinically based, aligned with other quality initiatives of the carrier or organization, and aligned with other carriers' and organizations' prior authorization criteria for the same health-care services;

(II) Ensure that prior authorization requests are reviewed by appropriate providers; and

(III) Make eligibility, benefit coverage, and medical policy determinations as part of the prior authorization process.

(b) [Editor's note: For the applicability of this subsection (4)(b) on or after January 1, 2026, see the editor's note following this section.]

(I) Carriers and organizations shall consider limiting the use of prior authorization to providers whose prescribing or ordering patterns differ significantly from the patterns of their peers after adjusting for patient mix and other relevant factors and present opportunities for improvement in adherence to the carrier's or organization's prior authorization requirements.

(II) No later than January 1, 2026, a carrier or an organization shall adopt a program, developed in consultation with providers participating with the carrier, to eliminate or substantially modify prior authorization requirements in a manner that removes the administrative burden for qualified providers, as defined under the program, and their patients for certain health-care services and related benefits based on any of the following:

(A) The performance of providers with respect to adherence to nationally recognized, evidence-based medical guidelines, appropriateness, efficiency, and other quality criteria; and

(B) Provider specialty, experience, or other objective factors; except that eligibility for the program must not be limited by provider specialty.

(III) A program developed pursuant to subsection (4)(b)(II) of this section:

(A) Must not require qualified providers to request participation in the program; and

(B) May include limiting the use of prior authorization to providers whose prescribing or ordering patterns differ significantly from the patterns of their peers after adjusting for patient mix and other relevant factors and in order to present those providers with opportunities for improvement in adherence to the carrier's or organization's prior authorization requirements.

(IV) At least annually, a carrier or an organization shall:

(A) Reexamine a provider's prescribing or ordering patterns;

(B) Reevaluate the provider's status for exemption from prior authorization requirements or for inclusion in the program developed pursuant to subsection (4)(b)(II) of this section; and

(V) A program developed pursuant to subsection (4)(b)(II) of this section must include procedures for a provider to request:

(A) An expedited, informal resolution of a carrier's or an organization's failure or refusal to include the provider in the program; and

(B) If the matter is not resolved through informal resolution, binding arbitration as specified in subsection (4)(b)(VI) of this section.

(VI) If a provider requests binding arbitration pursuant to the procedures a carrier or an organization develops under subsection (4)(b)(V)(B) of this section, the following provisions govern the arbitration procedure:

(A) The provider and carrier or organization shall jointly select an arbitrator from the list of arbitrators approved pursuant to section 10-16-704 (15)(b). Neither the provider nor the carrier or organization is required to notify the division of the arbitration or of the selected arbitrator.

(B) The selected arbitrator shall determine the provider's eligibility to participate in the carrier's or organization's program based on the program criteria developed pursuant to subsection (4)(b)(II) of this section;

(C) Within thirty days after the date the arbitrator accepts the matter, the provider and the carrier or organization shall submit to the arbitrator written materials in support of their respective positions;

(D) The arbitrator may render a decision based on the written materials submitted pursuant to subsection (4)(b)(VI)(C) of this section or may schedule a hearing, lasting not longer than one day, for the provider and carrier or organization to present evidence;

(E) Within thirty days after the date the arbitrator receives the written materials or, if a hearing is conducted, the date of the hearing, the arbitrator shall issue a written decision stating whether the provider is eligible for the program; and

(F) If the arbitrator overturns the carrier's or organization's failure or refusal to include the provider in the program, the carrier or organization shall pay the arbitrator's fees and costs, and if the arbitrator affirms the carrier's or organization's failure or refusal to include the provider in the program, the provider shall pay the arbitrator's fees and costs.

(c) [Editor's note: For the applicability of this subsection (4)(c) on or after January 1, 2026, see the editor's note following this section.]

(I) When a carrier or an organization approves a prior authorization request for a surgical procedure for which prior authorization is required, the carrier or organization shall not deny a claim for an additional or a related health-care procedure identified during the authorized surgical procedure if:

(A) The provider, while providing the approved surgical procedure to treat the covered person, determines, in accordance with generally accepted standards of medical practice, that providing a related health-care procedure, instead of or in addition to the approved surgical procedure, is medically necessary as part of the treatment of the covered person and that, in the provider's clinical judgment, to interrupt or delay the provision of care to the covered person in order to obtain prior authorization for the additional or related health-care procedure would not be medically advisable;

(B) The additional or related health-care procedure is a covered benefit under the covered person's health benefit plan;

(D) After completing the additional or related health-care procedure and before submitting a claim for payment, the provider notifies the carrier or organization that the provider performed the additional or related health-care procedure and includes in the notice the information required under the carrier's or organization's current prior authorization requirements posted in accordance with subsection (2)(a)(I) of this section; and

(E) The provider is compliant with the carrier's or organization's post-service claims process, including submission of the claim within the carrier's or organization's required timeline for claims submissions.

(II) When a provider provides an additional or a related health-care procedure as described in this subsection (4)(c), the carrier or organization shall not deny the claim for the initial surgical procedure for which the carrier or organization approved a prior authorization request on the basis that the provider provided the additional or related health-care procedure.

(5) Duration of approval. (a) [Editor's note: For the applicability of this subsection (5)(a) on or after January 1, 2026, see the editor's note following this section.] Upon approval by the carrier or organization, a prior authorization is valid for at least one calendar year after the date of approval and continues for the duration of the authorized course of treatment. Except as provided in subsection (5)(b) of this section, once approved, a carrier or an organization shall not retroactively deny the prior authorization request for a health-care service.

(b) If there is a change in coverage of or approval criteria for a previously approved health-care service, the change in coverage or approval criteria does not affect a covered person who received prior authorization before the effective date of the change for the remainder of the covered person's plan year.

(I) The prior authorization approval was based on fraud;

(II) The provider never performed the services that were requested for prior authorization;

(III) The service provided did not align with the service that was authorized;

(IV) The person receiving the service no longer had coverage under the health coverage plan on or before the date the service was delivered; or

(V) The covered person's benefit maximums were reached on or before the date the service was delivered.

(6) Rules - enforcement. [Editor's note: For the applicability of this subsection (6) on or after January 1, 2026, see the editor's note following this section.]

(a) The commissioner may adopt rules as necessary to implement this section.

(b) The commissioner may enforce the requirements of this section and impose a penalty or other remedy against a person that violates this section.

(7) Definitions. As used in this section:

(a) Approval means a determination by a carrier or organization that a health-care service has been reviewed and, based on the information provided, satisfies the carrier's or organization's requirements for medical necessity and appropriateness and that payment will be made for that health-care service.

(b) Clinical criteria means the written policies, written screening procedures, drug formularies or lists of covered drugs, determination rules, determination abstracts, clinical protocols, practice guidelines, medical protocols, and other criteria or rationale used by the carrier or organization to determine the necessity and appropriateness of health-care services.

(c) Medical necessity means a determination by the carrier that a prudent provider would provide a particular covered health-care service to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or symptom in a manner that is:

(I) In accordance with generally accepted standards of medical practice and approved by the FDA or other required agency;

(II) Clinically appropriate in terms of type, frequency, extent, service site, and level and duration of service;

(III) Known to be effective in improving health, as proven by scientific evidence;

(IV) The most appropriate supply, setting, or level of service that can be safely provided given the patient's condition and that cannot be omitted;

(V) Not experimental or investigational;

(VI) Not more costly than an alternative drug, service, service site, or supply that is not contraindicated for the patient's condition or safety and is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of an illness, injury, disease, or symptom; and

(VII) Not primarily for the economic benefit of carriers and purchasers or for the convenience of the patient, treating provider, or other provider.

(d) Prior authorization means the process by which a carrier or organization determines the medical necessity and appropriateness of otherwise covered health-care services prior to the rendering of the services. Prior authorization includes preadmission review, pretreatment review, utilization review, and case management and a carrier's or organization's requirement that a covered person or provider notify the carrier or organization prior to receiving or providing a health-care service.

(e) [Editor's note: For the applicability of this subsection (7)(e) on or after January 1, 2026, see the editor's note following this section.] Private utilization review organization or organization means a private utilization review organization, as defined in section 10-16-112 (1)(a), that has a contract with and performs prior authorization on behalf of a carrier.

(f) Urgent health-care service means a health-care service that, in the opinion of the provider based on the covered person's medical condition, if subjected to the prior authorization time period for a nonurgent health-care service, could:

(I) Seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function;

(II) For a person with a physical or mental disability, create an imminent and substantial limitation on the person's existing ability to live independently; or

(III) Subject the covered person to severe pain that cannot be adequately managed without the particular health-care service.

Source: L. 2019: Entire section added, (HB 19-1211), ch. 165, p. 1904, � 2, effective August 2. L. 2022: (7)(c)(I) amended, (HB 22-1264), ch. 126, p. 888, � 3, effective August 10. L. 2024: (2)(a), (2)(c), (3)(a)(I), (3)(c)(II), (4)(b), (5)(a), (6), and (7)(e) amended and (3)(c)(III), (3.5), and (4)(c) added, (HB 24-1149), ch. 333, p. 2255, � 2, effective August 7.

Editor's note: Section 5(2) of chapter 333 (HB 24-1149), Session Laws of Colorado 2024, provides that the act changing this section applies to conduct occurring on or after January 1, 2026.

Cross references: For the legislative declaration in HB 19-1211, see section 1 of chapter 165, Session Laws of Colorado 2019. For the legislative declaration in HB 24-1149, see section 1 of chapter 333, Session Laws of Colorado 2024.

10-16-113. Procedure for denial of benefits - internal review - rules - definitions. (1) (a) A carrier shall not make an adverse determination, in whole or in part, with respect to a health coverage plan unless the determination is made pursuant to this section.

(b) For the purposes of this section:

(I) Adverse determination means:

(A) A denial of a preauthorization for a covered benefit;

(B) A denial of a request for benefits for an individual on the ground that the treatment or covered benefit is not medically necessary, appropriate, effective, or efficient or is not provided in or at the appropriate health-care setting or level of care;

(C) A rescission or cancellation of coverage under a health coverage plan that is not attributable to failure to pay premiums and that is applied retroactively;

(D) A denial of a request for benefits on the ground that the treatment or service is experimental or investigational; or

(E) A denial of coverage to an individual based on an initial eligibility determination for all individual sickness and accident insurance policies issued by an entity subject to part 2 of this article, and all individual health-care or indemnity contracts issued by an entity subject to part 3 or 4 of this article, except supplemental policies covering a specified disease or other limited benefit.

(III) Individual means a person and includes the designated representative of an individual.

(c) If a carrier denies a benefit because the treatment is an excluded benefit and the claimant presents evidence from a medical professional licensed pursuant to the Colorado Medical Practice Act, article 240 of title 12, or, for dental plans only, a dentist licensed pursuant to the Dental Practice Act, article 220 of title 12, acting within his or her scope of practice, that there is a reasonable medical basis that the contractual exclusion does not apply to the denied benefit, such evidence establishes that the benefit denial is subject to the appeals process pursuant to this section and section 10-16-113.5.

(2) Following a denial of a request for benefits or an adverse determination by the carrier, the carrier shall notify the individual in writing. The commissioner shall adopt rules specifying the content of the notification and the deadlines for making the notification, and the carrier shall notify the individual in accordance with those rules.

(3) (a) (I) All denials of requests for reimbursement for medical treatment, standing referrals, or adverse determinations made on the ground that a treatment or covered benefit is not medically necessary, appropriate, effective, or efficient, is not delivered in the appropriate setting or at the appropriate level of care, or is experimental or investigational, must include:

(A) An explanation of the specific medical basis for the denial;

(B) The specific reasons for the denial or adverse determination;

(D) A description of the carrier's review procedures and the time limits applicable to such procedures and a statement that the individual has the right to appeal the decision; and

(E) A description of any additional material or information necessary, if any, for the individual to perfect the request for benefits and an explanation of why the material or information is necessary.

(II) In the case of an adverse determination by a carrier:

(A) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, the carrier shall furnish the individual with either the specific rule, guideline, protocol, or other similar criterion, or a statement that the rule, guideline, protocol, or other criterion was relied upon in making the adverse determination and that a copy of the rule, guideline, protocol, or other criterion will be provided free of charge to the individual upon request; or

(B) If the adverse determination is based on a medical necessity or experimental treatment or similar exclusion or limit, the carrier shall furnish the individual with either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the individual's medical circumstances, or a statement that the explanation will be provided free of charge upon request.

(III) In the event of an adverse determination by a carrier concerning a request involving urgent care, a carrier:

(A) Shall provide to the individual a description of the expedited review process applicable to the request;

(B) May communicate the other information required pursuant to subparagraph (I) of this paragraph (a) to the individual orally within the time frame outlined in 29 CFR 2560.503-1 (f)(2)(i) so long as a written or electronic copy of the information is furnished to the individual no later than three days after the oral notification; and

(C) May waive the deadlines specified in sub-subparagraph (B) of this subparagraph (III) and in subparagraph (IV) of this paragraph (a) to permit the individual to pursue an expedited external review of the urgent care claim under section 10-16-113.5.

(IV) A carrier shall notify an individual of a benefit determination, whether adverse or not, with respect to a request involving urgent care as soon as possible, taking into account the medical exigencies, but not later than seventy-two hours after the receipt of the request by the carrier, unless the individual fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the coverage.

(b) (I) A group health coverage plan issued by a carrier subject to part 2, 3, or 4 of this article must specify that an appeal of any adverse determination includes a two-level internal review of the decision, followed by the right of the individual to request an external review if allowed under section 10-16-113.5. The individual has the option of choosing whether to utilize the voluntary second-level internal appeal process.

(II) The carrier shall notify the individual of his or her right to appeal a denial of benefits through a two-level internal review process and that the second level of internal review may be utilized at the individual's option.

(III) (A) A physician shall evaluate the first-level appeal and shall consult with an appropriate clinical peer or peers, unless the reviewing physician is a clinical peer; except that, in the case of dental care, a dentist may evaluate the first-level appeal, and the reviewing dentist shall consult with an appropriate clinical peer or peers, unless the reviewing dentist is a clinical peer. A physician, dentist, or clinical peer who was involved in the initial adverse determination shall not evaluate or be consulted regarding the first-level appeal. A person who was previously involved with the denial may answer questions.

(B) This subparagraph (III) does not apply to an adverse determination described in sub-subparagraph (C) or (E) of subparagraph (I) of paragraph (b) of subsection (1) of this section.

(IV) (A) The second-level internal review of an appeal from the denial of a request for covered benefits pursuant to subparagraph (I) of this paragraph (b) shall be reviewed by a health-care professional who has appropriate expertise, who was not previously involved in the appeal, and who does not have a direct financial interest in the appeal or outcome of the review.

(B) The carrier shall allow the individual to be present for the second-level internal review, either in person or by telephone conference. The individual may bring counsel, advocates, and health-care professionals to the review, prepare in advance for the review, and present materials to the health-care professional prior to the review and at the time of the review. Upon request, the carrier and the individual shall provide copies of the materials they intend to present at the review to the other party at least five days prior to the review. If new information is developed after the five-day deadline, the material may be presented when practicable. The carrier shall notify the individual that the carrier will make an audio or video recording of the review unless neither the individual nor the carrier wants the recording made. If a recording is made, the carrier shall make the recording available to the individual. If there is an external review, the carrier shall include the audio or video recording in the material provided by the carrier to the reviewing entity if requested by either party.

(c) In addition to the requirements specified in subsections (3)(a) and (3)(b) of this section, unless a denial is based on nonpayment of premiums, a denial of reimbursement for services for the prevention of, screening for, or treatment of behavioral, mental health, and substance use disorders under a health benefit plan must include the following, in plain language:

(I) A statement explaining that covered persons are protected under the MHPAEA, which provides that limitations placed on access to mental health and substance use disorder benefits may be no greater than any limitations placed on access to medical and surgical benefits;

(II) A statement providing information about contacting the division or the office of the ombudsman for behavioral health access to care established pursuant to part 3 of article 80 of title 27 if the covered person believes his or her rights under the MHPAEA have been violated; and

(III) A statement specifying that covered persons are entitled, upon request to the carrier and free of charge, to a copy of the medical necessity criteria for any behavioral, mental health, and substance use disorder benefit.

(4) (a) Each carrier issuing individual health coverage plans shall notify the individual of his or her right to appeal an adverse determination through a single level of internal review.

(b) (I) A physician shall evaluate the appeal and consult with an appropriate clinical peer or peers unless the reviewing physician is a clinical peer; except that, in the case of dental care, a dentist may evaluate the appeal, and the reviewing dentist shall consult with an appropriate clinical peer or peers. A physician, dentist, or clinical peer who was involved in the initial adverse determination shall not evaluate or be consulted regarding the appeal. A person who was previously involved with the denial may answer questions.

(II) This paragraph (b) does not apply to an adverse determination described in sub-subparagraph (C) or (E) of subparagraph (I) of paragraph (b) of subsection (1) of this section.

(c) The carrier shall allow the individual to be present for the appeal. The individual may bring counsel, advocates, and health-care professionals to the review, prepare in advance for the review, and present materials to the physician or dentist prior to the review and at the time of the review. Upon request, the carrier and the individual shall provide copies of the materials they intend to present at the review to the other party at least five days prior to the review. If new information is developed after the five-day deadline, the material may be presented when practicable. The carrier shall notify the individual that the carrier will make an audio or video recording of the review unless neither the individual nor the carrier wants the recording made. If a recording is made, the carrier shall make the recording available to the individual. If there is an external review, the carrier shall include the audio or video recording in the material provided by the carrier to the reviewing entity if requested by either party.

(5) All written adverse determinations, except an adverse determination described in sub-subparagraph (C) or (E) of subparagraph (I) of paragraph (b) of subsection (1) of this section, must be signed by a licensed physician familiar with standards of care in Colorado; except that, in the case of written adverse determinations relating to dental care, a licensed dentist familiar with standards of care in Colorado may sign the written adverse determination.

(6) An individual's health-care provider may communicate with the physician or dentist involved in the initial decision to make an adverse determination.

(7) Nothing in this section precludes or denies the right of an individual to seek any other remedy or relief.

(8) In the case of the failure of a carrier to adhere to the requirements of this section with respect to a coverage request, the individual may be deemed to have exhausted the internal claims and appeals process of this section if the commissioner determines that the carrier did not substantially comply with the requirements of this section or that any error the carrier committed was not de minimis, as defined by the commissioner by rule, in which case the individual may initiate an external review under section 10-16-113.5.

(9) Carriers shall maintain records of all requests and notices associated with the internal claims and appeals process for six years and shall make such records available upon request for examination by the individual, the division of insurance, or the federal government.

(10) The commissioner may promulgate rules as necessary for the implementation and administration of this section.

Source: L. 97: Entire section added, p. 1334, � 1, effective July 1. L. 99: (3) amended, p. 320, � 4, effective July 1; (3) amended, p. 1047, � 1, effective June 1, 2000. L. 2003: (1) to (4), (6), and (7) amended, p. 1384, � 1, effective January 1, 2004. L. 2004: (3)(b)(I) amended, p. 988, � 7, effective August 4. L. 2005: (1)(c), (3)(b)(IV), (3)(b)(V), and (3)(b)(VI) added and (3)(b)(I) amended, p. 803, �� 1, 2, effective January 1, 2006. L. 2008: (3)(b)(V), (4), and (5) amended, p. 83, � 1, effective August 5. L. 2013: Entire section amended, (HB 13-1266), ch. 217, p. 956, � 19, effective May 13. L. 2014: (1)(c) amended, (HB 14-1277), ch. 363, p. 1735, � 37, effective July 1. L. 2019: (3)(c) added, (HB 19-1269), ch. 195, p. 2128, � 6, effective May 16; (1)(c) amended, (HB 19-1172), ch. 136, p. 1654, � 44, effective October 1.

Editor's note: Amendments to subsection (3) by House Bill 99-1306 and Senate Bill 99-141 were harmonized.

Cross references: (1) For the legislative declaration contained in the 1999 act amending subsection (3), see section 1 of chapter 111, Session Laws of Colorado 1999.

(2) For the short title (Behavioral Health Care Coverage Modernization Act) in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.

10-16-113.5. Independent external review of adverse determinations - legislative declaration - definitions - rules. (1) The general assembly hereby finds, determines, and declares that, in the interest of improving accountability for health-care coverage decisions, individuals should have the option of an independent external review by qualified experts when there has been an adverse determination with respect to a health coverage plan pursuant to a carrier's procedures as required by section 10-16-113.

(2) As used in this section, unless the context otherwise requires:

(a) Adverse determination means a denial of:

(I) A preauthorization for a covered benefit;

(II) A request for benefits for an individual on the grounds that the treatment or covered benefit is not medically necessary, appropriate, effective, or efficient or is not provided in or at the appropriate health-care setting or level of care;

(III) A request for benefits on the grounds that the treatment or services are experimental or investigational;

(IV) A benefit as described in section 10-16-113 (1)(c); or

(V) A request for benefits for a prescription drug that is unavailable in the state because a manufacturer has withdrawn the prescription drug from sale or distribution within the state under section 10-16-1412.

(b) Division means the division of insurance in the department of regulatory agencies, established in section 10-1-103.

(c) Expedited review means a review following completion of procedures for expedited internal review of an adverse determination involving a situation where the time frame of the standard independent external review procedures would seriously jeopardize the life or health of the individual or would jeopardize the individual's ability to regain maximum function. Expedited review is available if the adverse determination concerns an admission, availability of care, continued stay, or health-care services for which the individual received emergency services, and the individual has not been discharged from a facility.

(d) (I) Expert reviewer means a physician or other appropriate health-care provider assigned by an independent external review entity to conduct an independent external review. An expert reviewer shall not:

(A) Have been involved in the individual's care previously;

(B) Be a member of the board of directors of the carrier;

(D) Have a direct financial interest in the case or in the outcome of the review; or

(E) Be an employee of the carrier.

(II) Physicians or other appropriate health-care providers who are expert reviewers must:

(A) Be experts in the treatment of the medical condition of the individual requesting an independent external review and knowledgeable about the recommended treatment or service that is the subject of the review through the expert's actual, current clinical experience;

(B) Hold a license issued by a state and, for physicians, a current certification by a recognized American medical specialty board in the area appropriate to the subject of review; and

(C) Have no history of disciplinary action or sanction, including loss of staff privileges or participation restrictions, taken or pending by any hospital, government, or regulatory body.

(e) (I) Except as specified in subparagraph (II) of this paragraph (e), health coverage plan has the same meaning as set forth in section 10-16-102 (34).

(II) Health coverage plan does not include insurance arising out of the Workers' Compensation Act of Colorado, articles 40 to 47 of title 8, C.R.S., or other similar law, automobile medical payment insurance, property and casualty insurance, or insurance under which benefits are payable with or without regard to fault and that is required by law to be contained in any liability insurance policy or equivalent self-insurance.

(f) Independent external review entity means an entity that meets the requirements of this section, is accredited by a nationally recognized private accrediting organization, and is certified by the commissioner to conduct independent external reviews of adverse determinations by a carrier.

(g) (I) Individual requesting an independent external review means a covered person who:

(A) Has gone through at least one of the internal appeals review levels offered by a carrier and established pursuant to section 10-16-113 and has requested an independent external review of a carrier's decision to uphold an adverse determination; or

(B) Has pursued an expedited review of an adverse determination.

(II) Individual requesting an independent external review also includes the designated representative of an individual requesting an independent external review.

(h) Medical and scientific evidence includes the following sources:

(I) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;

(II) Peer-reviewed literature, biomedical compendia, and other medical literature that meet the criteria of the national institute of health's national library of medicine for indexing in index medicus, excerpta medicus (EMBASE), medline, and MEDLARS database of health services technology assessment research (HSTAR);

(III) Medical journals recognized by the United States secretary of health and human services, pursuant to section 1861 (t)(2) of the federal Social Security Act, 42 U.S.C. sec. 1395x;

(IV) The following standard reference compendia:

(A) The American hospital formulary service-drug information;

(B) The American medical association drug evaluation;

(D) The United States pharmacopoeia - drug information.

(V) Findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including the federal agency for health care policy and research, national institutes of health, the national cancer institute, the national academy of sciences, the health care financing administration, the congressional office of technology assessment, and the national board recognized by the national institutes of health for the purpose of evaluating the medical value of health services.

(3) Carriers shall make available an independent external review process that meets the requirements of this section. The carrier shall pay the cost of an independent external review. There is no restriction on the minimum dollar amount of a claim for it to be eligible for external review.

(4) (a) To qualify for certification by the commissioner as an independent external review entity, the entity must meet the following requirements:

(I) The independent external review entity shall ensure that cases are reviewed by expert reviewers knowledgeable about the recommended treatment or service through the expert reviewers' actual, current clinical experience and who have appropriate expertise in the same or similar specialties as would typically manage the case being reviewed.

(II) The independent external review entity shall ensure that the decision is based upon a case review that includes a review of the medical records of the individual requesting an independent external review and a review of relevant medical and scientific evidence.

(III) The independent external review entity shall have a quality assurance procedure that ensures the timeliness and quality of the reviews conducted pursuant to this section, the qualifications and independence of the expert reviewers, and the confidentiality of medical records and review materials.

(IV) The independent external review entity shall maintain patient confidentiality pursuant to Colorado and federal law.

(b) In addition to the requirements set forth in paragraph (a) of this subsection (4), the commissioner shall certify only an independent external review entity that:

(I) Is not a subsidiary of, or owned or controlled by, a carrier, a trade association of carriers, or a professional association of health-care providers;

(II) Maintains documentation available for review by the division upon request that includes the following:

(A) The names of all stockholders and owners of more than five percent of stock or options;

(B) The names of all holders of bonds or notes in amounts in excess of one hundred thousand dollars;

(C) The names of all corporations and organizations that the independent external review entity controls or is affiliated with, and the nature and extent of any ownership or control, including the affiliated organization's business activities;

(D) The names of all directors, officers, and executives of the independent external review entity and a statement regarding any relationship the directors, officers, or executives may have with any carrier;

(III) Does not have any material professional, family, or financial conflict of interest with:

(A) The carrier or any officer, director, or executive of the carrier. This requirement does not prohibit a physician or qualified health-care professional who contracts with the carrier as a participating provider from serving on a review panel of the independent external review entity if the physician or qualified health-care professional meets the requirements of paragraph (d) of subsection (2) of this section. If a participating provider serves on the panel reviewing the case of an individual requesting an independent external review, the review entity shall notify the individual requesting an independent external review that a health-care professional serving on the review panel has a contract as a participating provider with the carrier.

(B) The physician or physician's medical group that treated the individual requesting an independent external review;

(D) The development or manufacture of the principal drug, device, procedure, treatment, or service proposed for the individual requesting an independent external review whose treatment is under review; or

(E) The individual requesting an independent external review.

(c) Nothing in subparagraph (III) of paragraph (b) of this subsection (4) includes affiliations that are limited to staff privileges at a health-care institution.

(d) The commissioner shall promulgate rules as necessary for the certification of independent external review entities under this section. The commissioner may deny, suspend, or revoke the certification of an independent external review entity that does not comply with the requirements of this section. The commissioner may contract with any person or entity to develop the certification rules and for implementation and administration of the certification program.

(5) Upon receipt of a request from an individual requesting an independent external review of a denial, the carrier shall contact the division. The division or its contractor shall inform the carrier of the name of the independent external review entity to which the appeal should be sent.

(6) All health coverage plan materials dealing with the carrier's grievance procedures must advise individuals in writing of the availability of an independent external review process, the circumstances under which an individual requesting an independent external review may use the independent external review process, the procedures for requesting an independent external review, and the deadlines associated with an independent external review.

(7) An individual requesting an independent external review shall make the request within four months after receiving notification of the denial of the individual's internal appeal of an adverse determination. In the internal appeal denial notification, the carrier shall inform the individual of his or her right to an independent external review. An individual requesting an independent external review shall notify the carrier if the individual requests an expedited review. An individual requesting an expedited independent external review may obtain such external review concurrently with an expedited internal appeal request under section 10-16-113.

(8) An individual may request an independent external review or an expedited independent external review involving a denial of coverage of a recommended or requested medical service that is experimental or investigational if the individual's treating physician certifies in writing that the recommended or requested health-care service or treatment that is the subject of the denial would be significantly less effective if not promptly initiated. The individual's treating physician must certify in writing that at least one of the following situations applies:

(a) Standard health-care services or treatments have not been effective in improving the condition of the individual or are not medically appropriate for the individual; or

(b) There is no available standard health-care service or treatment covered by the carrier that is more beneficial than the recommended or requested health-care service, and the physician is a licensed, board-certified or board-eligible physician qualified to practice in the area of medicine appropriate to treat the individual's condition. The physician must certify that scientifically valid studies using accepted protocols demonstrate that the health-care service or treatment requested by the individual that is the subject of the denial is likely to be more beneficial to the individual than any available standard health-care services or treatments.

(8.5) An individual requesting an independent external review may request the review or an expedited review to determine if section 10-16-704 (3) or (5.5) applies to the items or services that were provided or may be provided to a covered person by an out-of-network provider or at an out-of-network facility.

(9) After receipt of a written request for an independent external review, the carrier shall notify the individual requesting an independent external review in writing. The notification must include descriptive information on the independent external review entity that the division or its contractor has selected to conduct the independent external review.

(10) (a) The carrier shall provide to the independent external review entity a copy of the following documents after the division or its contractor has selected an independent external review entity for the case:

(I) Any information submitted to the carrier, under the carrier's procedures, in support of the request for an independent external review, by an individual requesting the review or by the physician or other health-care professional of the individual seeking the review. The independent external review entity shall maintain the confidentiality of any medical records submitted pursuant to this subsection (10).

(II) A copy of any relevant documents used by the carrier in making its adverse determination on the proposed service or treatment, and a copy of any denial letters issued by the carrier concerning the individual case under review. The carrier shall provide, upon request to the individual requesting an independent external review, all relevant information supplied to the independent external review entity that is not confidential or privileged under state or federal law concerning the individual case under review.

(III) The individual requesting an independent external review may submit additional information directly to the independent external review entity within five business days after the notification under subsection (9) of this section. The independent external review entity shall provide a copy of the information submitted by the individual to the carrier whose adverse determination is being reviewed within one business day after receipt of the information.

(b) The independent external review entity shall notify the individual requesting an independent external review, the physician or other health-care professional of the individual requesting an independent external review, and the carrier of any additional medical information required to conduct the review after receipt of the documentation required or provided pursuant to this subsection (10). The individual requesting an independent external review or the physician or other health-care professional of the individual requesting an independent external review shall submit the additional information, or an explanation of why the additional information is not being submitted, to the independent external review entity and the carrier after the receipt of such a request.

(c) The carrier may determine that additional information provided by the individual requesting independent external review or the physician or other health-care professional of the individual requesting independent external review under subparagraph (III) of paragraph (a) and paragraph (b) of this subsection (10) justifies a reconsideration of its adverse determination, and a subsequent decision by the carrier to provide coverage terminates the independent external review upon notification in writing to the independent external review entity and the individual requesting an independent external review.

(11) (a) The independent external review entity shall submit the expert determination to the carrier, the individual requesting independent external review, and the physician or other health-care professional of the individual requesting an independent external review within forty-five calendar days after the independent external review entity has received a request for external review. In the case of an expedited review, the independent external review entity shall submit the determinations as expeditiously as possible and no more than seventy-two hours after the independent external review entity received a request for an expedited external review. If the notice of the determination in an expedited review is not made in writing, the independent external review entity shall provide written confirmation of the decision within forty-eight hours after the date the notice of decision is transmitted to the individual, the physician, or other health-care professional.

(b) The expert reviewer's determination must:

(I) Be in writing and state the reasons the requested treatment or service should or should not be covered;

(II) Specifically cite the relevant provisions in the health coverage plan documentation, the specific medical condition of the individual requesting an independent external review, and the relevant documents provided pursuant to this section to support the expert reviewer's determination; and

(III) Be based on an objective review of relevant medical and scientific evidence.

(I) The titles and qualifying credentials of the persons conducting the review;

(II) A statement of the understanding of the persons conducting the review of the nature of the grievance and all pertinent facts;

(III) The rationale for the decision;

(IV) Reference to medical and scientific evidence and documentation considered in making the determination; and

(V) In cases involving a determination adverse to the individual requesting an independent external review, the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination.

(12) The determinations of the expert reviewer are binding on the carrier and on the individual requesting independent external review. A determination of the expert reviewer in favor of the individual requesting independent external review creates a rebuttable presumption in any subsequent action that the carrier's adverse determination was not appropriate. A determination of the expert reviewer in favor of the carrier creates a rebuttable presumption in any subsequent action that the carrier's adverse determination was appropriate.

(13) Where an expert determination is made in favor of the individual requesting an independent external review, the carrier shall provide coverage for the treatment and services required under this section subject to the terms and conditions applicable to benefits under the health coverage plan.

(14) An independent external review entity and an expert reviewer assigned by the independent external review entity to conduct a review pursuant to this section are immune from civil liability in any action brought by any person based upon the determinations made pursuant to this section. This subsection (14) does not apply to an act or omission of the independent external review entity that is made in bad faith or involves gross negligence.

(15) A carrier is not liable for damages arising from any act or omission of the independent external review entity.

(16) A carrier may require a surety bond to indemnify the carrier for the independent external review entity's noncompliance with this section.

(17) An independent external review entity shall maintain written records of reviews on all requests for external review for which it was assigned to conduct an external review for at least three years.

Source: L. 99: Entire section added, p. 1048, � 2, effective June 1, 2000. L. 2005: (2)(a)(I)(A) amended, p. 805, � 3, effective January 1, 2006. L. 2013: Entire section amended, (HB 13-1266), ch. 217, p. 961, � 20, effective May 13. L. 2016: (2)(f) amended, (SB 16-189), ch. 210, p. 756, � 15, effective June 6. L. 2022: (8.5) added, (HB 22-1284), ch. 446, p. 3133, � 1, effective August 10. L. 2023: (2)(a)(III) and (2)(a)(IV) amended and (2)(a)(V) added, (HB 23-1225), ch. 162, p. 709, � 10, effective August 7.