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Code of Colorado Regulations eDocket
Official Publication of the State Administrative Rules (24-4-103(11) C.R.S.)

Details of Tracking Number  2020-00916


CCR details

Tracking Number 2020-00916
Type of Filing Permanent Rule
Department 700 Department of Regulatory Agencies
Agency 702 Division of Insurance
CCR Number 3 CCR 702-4
CCR Title LIFE, ACCIDENT AND HEALTH

Proposed rule

Notice Filed with SOS 11/30/2020
Rule ProposedRuleAttach2020-00916.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 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.
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.
Comments Due to concerns with the spread of COVID-19, this Permanent RulemakingHearing will be held via WEBINAR ONLY, unless the COVID-19 State ofEmergency is lifted by the date of the hearing. Please click on the link below orvisit the Division of Insurance's website on the Notice of RulemakingHearings/Proposed Regulations" page, which is located under the link to "Statutes,Regulations and Bulletins" found on the main page.https://www.colorado.gov/pacific/dora/notice-rule-making-hearings-proposed-regulations Please register here to attend the hearing via webinar:https://attendee.gotowebinar.com/register/644403285646661647 Webinar ID: 365-933-803 After registering, you will receive a confirmation email containinginformation about joining the webinar. Participants can use their telephone orcomputer mic & speakers (VoIP). UNITED STATES +1 (631) 992-3221 AUDIOPIN: 993-533-652
Submitted in response to issues raised by COLS/OLLS? No
Is this rule adopted in response to recent legislation? No
Hearing Date 01/05/2021
Hearing Time 10:00 AM
Hearing Location Webinar or 1560 Broadway, Suite 110D, Denver, CO 80202
Contact Name Christine Ferrer
Contact Title Rulemaking Coordinator
Contact Telephone 3038942157
Contact email christine.gonzales-ferrer@state.co.us

Adopted rule

Adopted Rules AdoptedRules12020-00916.doc
Redline Redline2020-00916.doc
Adopted Date 01/12/2021
AGO requested date 01/12/2021
Attorney General Opinion 01/22/2021
Colorado Register publication date 02/10/2021
Effective Date 03/15/2021