As used in this article 37, unless the context otherwise requires:
(1) Category of coverage means one of the following types of coverage offered by a person or entity:
(a) Health maintenance organization plans;
(b) Any other commercial plan or contract that is not a health maintenance organization plan;
(c) Medicare;
(d) Medicaid; or
(e) Workers' compensation.
(2) CMS means the federal centers for medicare and medicaid services in the United States department of health and human services.
(3) CPT code set means the current procedural terminology code, or its successor code, as developed and copyrighted by the American medical association, or its successor entity, and adopted by the CMS as a HIPAA code set.
(4) Repealed.
(5) HCPCS means the Healthcare Common Procedure Coding System developed by the CMS for identifying health-care services in a consistent and standardized manner.
(6) Health-care contract or contract means a contract entered into or renewed between a person or entity and a health-care provider for the delivery of health-care services to others.
(7) Health-care provider means a person licensed or certified in this state to practice medicine, pharmacy, chiropractic, nursing, physical therapy, podiatry, dentistry, optometry, occupational therapy; to practice as a certified midwife; or to practice other healing arts. Health-care provider also means an ambulatory surgical center, a licensed pharmacy or provider of pharmacy services, and a professional corporation or other corporate entity consisting of licensed health-care providers as permitted by the laws of this state.
(8) HIPAA code set means any set of codes used to encode elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes, that have been adopted by the secretary of the United States department of health and human services pursuant to the federal Health Insurance Portability and Accountability Act of 1996, as amended. HIPAA code set includes the codes and the descriptors of the codes.
(9) (a) Material change means a change to a contract that decreases the health-care provider's payment or compensation, changes the administrative procedures in a way that may reasonably be expected to significantly increase the provider's administrative expense, replaces the maximum allowable cost list used with a new and different maximum allowable cost list by a person or entity for reimbursement of generic prescription drug claims, or adds a new category of coverage.
(b) Material change does not include:
(I) A decrease in payment or compensation resulting solely from a change in a published fee schedule upon which the payment or compensation is based and the date of applicability is clearly identified in the contract;
(II) A decrease in payment or compensation resulting from a change in the fee schedule specified in a contract for pharmacy services such as a change in a fee schedule based on average wholesale price or maximum allowable cost;
(III) A decrease in payment or compensation that was anticipated under the terms of the contract, if the amount and date of applicability of the decrease is clearly identified in the contract;
(IV) An administrative change that may significantly increase the provider's administrative expense, the specific applicability of which is clearly identified in the contract;
(V) Changes to an existing prior authorization, precertification, notification, or referral program that do not substantially increase the provider's administrative expense; or
(VI) Changes to an edit program or to specific edits; however, the person or entity shall provide notice of the changes to the health-care provider in accordance with paragraph (c) of this subsection (9), and the notice shall include information sufficient for the health-care provider to determine the effect of the change.
(c) If a change to the contract is administrative only and is not a material change, the change shall be effective upon at least fifteen days' notice to the health-care provider. All other notices shall be provided pursuant to the contract.
(10) National correct coding initiative or NCCI means the system developed by the CMS to promote consistency in national correct coding methodologies and to control improper coding leading to inappropriate payment in medicare part B claims for professional services.
(11) National initiative means a collaborative effort led by or occurring under the direction of the secretary of the United States department of health and human services, which includes a diverse group of stakeholders, to create a level of understanding of the impact of coding edits on the industry and a uniform, standardized set of claim edits that meets the needs of the stakeholders in the industry.
(12) Person or entity means a person or entity that has a primary business purpose of contracting with health-care providers for the delivery of health-care services.
(13) Pharmacy benefit manager means an entity doing business in this state that contracts to administer or manage prescription drug benefits on behalf of any carrier that provides prescription drug benefits to residents of this state. Pharmacy benefit manager does not include the department of health care policy and financing created in section 25.5-1-104, C.R.S.
Source: L. 2010: Entire article amended with relocations, (HB 10-1332), ch. 300, p. 1413, � 1, effective May 26. L. 2014: (13) added, (HB 14-1213), ch. 362, p. 1702, � 1, effective January 1, 2015. L. 2016: (4) repealed, (SB 16-127), ch. 68, p. 173, � 2, effective July 1. L. 2023: IP and (7) amended, (SB 23-167), ch. 261, p. 1549, � 61, effective May 25.
Editor's note: This section is similar to former � 25-37-101 (2) as it existed prior to 2010.
25-37-103. Health-care contracts - required provisions - permissible provision. (1) (a) A person or entity shall provide, with each health-care contract, a summary disclosure form disclosing, in plain language, the following:
(I) The terms governing compensation and payment;
(II) Any category of coverage for which the health-care provider is to provide service;
(III) The duration of the contract and how the contract may be terminated;
(IV) The identity of the person or entity responsible for the processing of the health-care provider's claims for compensation or payment;
(V) Any internal mechanism required by the person or entity to resolve disputes that arise under the terms or conditions of the contract; and
(VI) The subject and order of addenda, if any, to the contract.
(b) The summary disclosure form required by paragraph (a) of this subsection (1) shall be for informational purposes only and shall not be a term or condition of the contract; however, such disclosure shall reasonably summarize the applicable contract provisions.
(c) If the contract provides for termination for cause by either party, the contract shall state the reasons that may be used for termination for cause, which terms shall not be unreasonable, and the contract shall state the time by which notice of termination for cause shall be provided and to whom the notice shall be given.
(d) The person or entity shall identify any utilization review or management, quality improvement, or similar program the person or entity uses to review, monitor, evaluate, or assess the services provided pursuant to a contract. The policies, procedures, or guidelines of such program applicable to a provider shall be disclosed upon request of the health-care provider within fourteen days after the date of the request.
(e) (I) The summary disclosure form required by subsection (1)(a) of this section must include a disclosure that a person or entity shall not terminate a health-care contract with a health-care provider solely for the provision of, or assistance in the provision of, a legally protected health-care activity, as defined in section 12-30-121 (1)(d).
(II) A person or entity that is a religious organization is not subject to the requirements of this subsection (1)(e) if the provision of, or assistance in the provision of, a legally protected health-care activity, as defined in section 12-30-121 (1)(d), conflicts with the religious organization's bona fide religious beliefs and practices.
(2) (a) The disclosure of payment and compensation terms pursuant to subsection (1) of this section shall include information sufficient for the health-care provider to determine the compensation or payment for the health-care services and shall include the following:
(I) The manner of payment, such as fee-for-service, capitation, or risk sharing;
(II) (A) The methodology used to calculate any fee schedule, such as relative value unit system and conversion factor, percentage of medicare payment system, or percentage of billed charges. As applicable, the methodology disclosure shall include the name of any relative value system; its version, edition, or publication date; any applicable conversion or geographic factor; and any date by which compensation or fee schedules may be changed by such methodology if allowed for in the contract.
(B) The fee schedule for codes reasonably expected to be billed by the health- care provider for services provided pursuant to the contract, and, upon request, the fee schedule for other codes used by or which may be used by the health-care provider. Such fee schedule shall include, as may be applicable, service or procedure codes such as current procedural terminology (CPT) codes or health care common procedure coding system (HCPCS) codes and the associated payment or compensation for each service code.
(C) The fee schedule required in sub-subparagraph (B) of this subparagraph (II) may be provided electronically.
(D) A fee schedule for the codes described by sub-subparagraph (B) of this subparagraph (II) shall be provided when a material change related to payment or compensation occurs. Additionally, a health-care provider may request that a written fee schedule be provided up to twice per year, and the person or entity must provide such fee schedule promptly.
(III) The person or entity shall state the effect of edits, if any, on payment or compensation. A person or entity may satisfy this requirement by providing a clearly understandable, readily available mechanism, such as through a website, that allows a health-care provider to determine the effect of edits on payment or compensation before service is provided or a claim is submitted.
(b) Notwithstanding any provision of this subsection (2) to the contrary, disclosure of a fee schedule or the methodology used to calculate a fee schedule is not required:
(I) From a person or entity if the fee schedule is for a plan for dental services, its providers include licensed dentists, the fee schedule is based upon fees filed with the person or entity by dental providers, and the fee schedule is revised from time to time based upon such filings. Specific numerical parameters are not required to be disclosed.
(II) If the fee schedule is for pharmacy services or drugs such as a fee schedule based on use of national drug codes.
(3) When a proposed contract is presented by a person or entity for consideration by a health-care provider, the person or entity shall provide in writing or make reasonably available the information required in subsections (1) and (2) of this section. If the information is not disclosed in writing, it shall be disclosed in a manner that allows the health-care provider to timely evaluate the payment or compensation for services under the proposed contract. The disclosure obligations in this article shall not prevent a person or entity from requiring a reasonable confidentiality agreement regarding the terms of a proposed contract.
(4) Nothing in this article shall be construed to require the renegotiation of a contract in existence before the applicable compliance date in this article, and any disclosure required by this article for such contracts may be by notice to the health-care provider.
(5) A contract subject to this article may include an agreement for binding arbitration.
Source: L. 2010: Entire article amended with relocations, (HB 10-1332), ch. 300, p. 1416, � 1, effective May 26. L. 2023: (1)(e) added, (SB 23-188), ch. 68, p. 251, � 25, effective April 14.
Editor's note: This section is similar to former � 25-37-101 (3), (4), (6), (9), and (19) as they existed prior to 2010.
Cross references: For the legislative declaration in SB 23-188, see section 1 of chapter 68, Session Laws of Colorado 2023.
25-37-103.5. Pharmacy benefit managers - contracts with pharmacies - maximum allowable cost pricing. (Repealed)
Source: L. 2014: Entire section added, (HB 14-1213), ch. 362, p. 1702, � 2, effective January 1, 2015. L. 2023: Entire section repealed, (HB 23-1227), ch. 160, p. 698, � 9, effective August 7.
Editor's note: This section was relocated to � 10-16-122.6 in 2023.
25-37-104. Material change in health-care contract - written advance notice. (1) A material change to a contract shall occur only if the person or entity provides in writing to the health-care provider the proposed change and gives ninety days' notice before the effective date of the change. The writing shall be conspicuously entitled notice of material change to contract.
(2) If the health-care provider objects in writing to the material change within fifteen days and there is no resolution of the objection, either party may terminate the contract upon written notice of termination provided to the other party not later than sixty days before the effective date of the material change.
(3) If the health-care provider does not object to the material change pursuant to subsection (2) of this section, the change shall be effective as specified in the notice of material change to the contract.
(4) If a material change is the addition of a new category of coverage and the health-care provider objects, the addition shall not be effective as to the health-care provider, and the objection shall not be a basis upon which the person or entity may terminate the contract.
Source: L. 2010: Entire article amended with relocations, (HB 10-1332), ch. 300, p. 1418, � 1, effective May 26.
Editor's note: This section is similar to former � 25-37-101 (7) as it existed prior to 2010.