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Code of Colorado Regulations eDocket
Details of Tracking Number
2019-00607
CCR details
| Tracking Number |
2019-00607 |
| Type of Filing |
Permanent Rule |
| Department |
700 Department of Regulatory Agencies |
| Agency |
702 Division of Insurance |
| CCR Number |
3 CCR 702-4 Series 4-2 |
| CCR Title |
LIFE, ACCIDENT AND HEALTH, Series 4-2 Accident and Health (General) |
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Proposed rule
| Notice Filed with SOS |
09/30/2019 |
| Rule |
ProposedRuleAttach2019-00607.doc |
| Statutory Authority |
§§ 10-1-109, 10-3-1110, 10-16-109, and 10-16-113(2) and (10), C.R.S. |
| Description of Subjects/Issues |
4-2-17 PROMPT INVESTIGATION OF HEALTH CLAIMS INVOLVING UTILIZATION REVIEW AND DENIAL OF BENEFITS AND RULES RELATED TO INTERNAL CLAIMS AND APPEALS PROCESSES - The purpose of this regulation is to set forth guidelines for carrier compliance with the provisions of §§ 10-3-1104(1)(h), 10-16-409(1)(a), and 10-16-113, C.R.S., in situations involving utilization review and certain denials of benefits for treatment, as well as rescission, cancellation, or denial of coverage based on an eligibility determination, as described herein. Among other things, § 10-3-1104(1)(h), C.R.S., requires carriers to adopt and implement reasonable standards for the prompt investigation of claims arising from health coverage plans; promptly provide a reasonable explanation of the basis in the health coverage plan in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement; and refrain from denying a claim without conducting a reasonable investigation based upon all available information. |
| Purpose/Objective of Rule |
The purpose of this regulation is to set forth guidelines for carrier compliance with the provisions of §§ 10-3-1104(1)(h), 10-16-409(1)(a), and 10-16-113, C.R.S., in situations involving utilization review and certain denials of benefits for treatment, as well as rescission, cancellation, or denial of coverage based on an eligibility determination, as described herein. Among other things, § 10-3-1104(1)(h), C.R.S., requires carriers to adopt and implement reasonable standards for the prompt investigation of claims arising from health coverage plans; promptly provide a reasonable explanation of the basis in the health coverage plan in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement; and refrain from denying a claim without conducting a reasonable investigation based upon all available information.
This regulation is designed to provide minimum standards for handling appeals and grievances involving utilization review determinations, certain denials of benefits for treatments excluded by health coverage plans, and as otherwise required by § 10-16-113, C.R.S |
| Submitted in response to issues raised by COLS/OLLS? |
No
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| Is this rule adopted in response to recent legislation? |
Yes
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| Recent legislation bill number |
HB 19-1211
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| Hearing Date |
11/01/2019 |
| Hearing Time |
02:00 PM |
| Hearing Location |
1560 Broadway, Ste 110D, Denver CO 80202 |
| Contact Name |
Christine Gonzales-Ferrer |
| Contact Title |
Rulemaking Coordinator |
| Contact Telephone |
303-894-2157 |
| Contact email |
christine.gonzales-ferrer@state.co.us |
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Adopted rule
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