Statutes, codes, and regulations
Colorado Administrative Code
Department 700 - Department of Regulatory AgenciesDivision 702 - Division of InsuranceRule 3 CCR 702-4 - LIFE, ACCIDENT AND HEALTHSection 3 CCR 702-4 Series 4-2 - LIFE, ACCIDENT AND HEALTH, Series 4-2 Accident and Health (General)
Regulation Regulation 4-2-17 - PROMPT INVESTIGATION OF HEALTH CLAIMS INVOLVING UTILIZATION REVIEW AND DENIAL OF BENEFITS AND RULES RELATED TO INTERNAL CLAIMS AND APPEALS PROCESSES
Section 3 CCR 702-4-2-17-4 - Definitions

3 Colo. Code Regs. § 702-4-2-17-4

Download
PDF
Current through Register Vol. 47, No. 24, December 25, 2024
Section 3 CCR 702-4-2-17-4 - Definitions
A. "Adverse determination" means, for the purposes of this regulation:
1. A determination by a carrier or its designee that a request for a prospective or retrospective benefit has been reviewed and, based upon the information provided, does not meet the carrier's requirement for medical necessity, or that the benefit is not appropriate, effective, efficient, is not provided in or at the appropriate health care setting or level of care, or is determined to be experimental or investigational, and is therefore denied, reduced, or terminated;
2. A denial for a benefit excluded by a health coverage plan for which the covered person is able to present evidence from a medical professional that there is a reasonable medical basis that the contractual exclusion does not apply to the denied benefit;
3. A rescission or cancellation of coverage applied retroactively that is not attributed to a failure to pay premiums. However, a physician is not required to evaluate an appeal of this type of adverse determination; and
4. A denial of coverage to an individual based on an initial eligibility determination for all:
a. Individual sickness and accident insurance policies issued by a carrier subject to Part 2 of Article 16 of Title 10; and
b. Individual health care or indemnity contracts issued by a carrier subject to Parts 3 or 4 of Article 16 of Title 10.

Section 4.A.4 does not apply to supplemental policies covering a specified disease or other limited benefit. A physician is not required to evaluate an appeal of this type of adverse determination.

B. "Ambulatory review" means, for the purposes of this regulation, a utilization review of health care services performed or provided in an outpatient setting.
C. "Applicable non-English language" means, for the purposes of this regulation, with respect to an address in any Colorado county to which a notice is sent, a non-English language that ten percent (10%) or more of the population residing in the county is only literate in as determined by the Secretary of the United States Department of Health and Human Services.
D. "Carrier" shall have the same meaning as found at § 10-16-102(8), C.R.S.
E. "Carrier's receipt" means, for the purposes of this regulation, the receipt date as date-stamped by the carrier in a legible manner; an electronically-formatted receipt date; a facsimile transmission date; or a receipt date imprinted on the document in some type of permanent manner. The earliest receipt date on the document will be considered the carrier's receipt date.
F. "Case management" means, for the purposes of this regulation, a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions.
G. "Clinical peer" means, for the purposes of this regulation, a physician or other health care professional who holds a non-restricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review.
H. "Complaint" means, for the purposes of this regulation, a written communication primarily expressing a grievance.
I. "Covered person" shall have the same meaning as found at § 10-16-102(15), C.R.S.
J. "Date of receipt of a notice" means, for the purposes of this regulation, the date that shall be calculated to be no less than three (3) calendar days after the date the notice is postmarked by the carrier.
K. "Designated representative" means, for the purposes of this regulation:
1. A person, including the treating health care professional or a person authorized by subsection 4.K.2., to whom a covered person has given express written consent to represent the covered person;
2. A person authorized by law to provide substituted consent for a covered person, including but not limited to a guardian, agent under a power of attorney, a proxy, or a designee of the Colorado Department of Health Care Policy and Financing; and/or
3. In the case of an urgent care request, a health care professional with knowledge of the covered person's medical condition.
L. "Disability" means, for the purposes of this regulation, with respect to a covered person, a physical or mental impairment that substantially limits one or more of the major life activities of such covered person, in accordance with the Americans with Disabilities Act of 1990, 42 U.S.C. § 12101.
M. "Discharge planning" means, for the purposes of this regulation, the formal process for determining, prior to discharge from a medical facility or service, the coordination and management of the care that a covered person receives following discharge from a medical facility or service.
N. "Emergency medical condition" means, for the purposes of this regulation, the sudden, and at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the covered person's health in serious jeopardy.
O. "Grievance" means, for the purposes of this regulation, a circumstance regarded as a cause for protest, including the protest of an adverse determination.
P. "Health care professional" means, for the purposes of this regulation, a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with state law.
Q. "Health care services" shall have the same meaning as found at § 10-16-102(33), C.R.S.
R. "Health coverage plan" shall have the same meaning as found at § 10-16-102(34), C.R.S.
S. "Life or limb threatening emergency" means, for the purposes of this regulation, any event that a prudent layperson would believe threatens his or her life or limb in such a manner that a need for immediate medical care is created to prevent death or serious impairment of health.
T. "Managed care plan" shall have the same meaning as found at § 10-16-102(43), C.R.S.
U. "Medical facility" means, for the purposes of this regulation, an institution providing health care services, or a health care setting, including but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.
V. "Medical professional" means, for the purposes of this regulation, an individual licensed pursuant to the "Colorado Medical Practice Act", article 240 of title 12, C.R.S., or, for dental plans only, a dentist licensed pursuant to the "Dental Practice Law of Colorado", article 220 of title 12, C.R.S., acting within his or her scope of practice.
W. "Notice of the adverse determination" and "notice of the initial adverse determination", for the purposes of this regulation, do not include an explanation of benefits (EOB) form.
X. "Prior authorization" shall have the same meaning as found at § 10-16-112.5(7)(d), C.R.S.
Y. "Prospective review" and "prospective utilization review" mean, for the purposes of this regulation, a utilization review conducted prior to an admission or course of treatment requested by a covered person, designated representative, medical facility, or health care professional. It does not include prior authorizations required by a carrier.
Z. "Rescission" means, for the purposes of this regulation, the cancellation or discontinuance of coverage that has a retroactive effect. This includes a cancellation that treats a policy as void from the time of enrollment and a cancellation that voids benefits paid up to a year before the cancellation takes place. A rescission of coverage shall be treated as an adverse determination. A cancellation or discontinuance of coverage is not a rescission if the cancellation or discontinuance is exclusively prospective, or the cancellation or discontinuance is retroactive only to the extent attributable to a failure to pay premiums or contributions toward the cost of coverage in a timely manner.
AA. "Retrospective review" and "retrospective utilization review" mean, for the purposes of this regulation, utilization review conducted after services have been provided to a covered person, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment.
AB. "Second opinion" means, for the purposes of this regulation, an opportunity or requirement to obtain a clinical evaluation by a health care professional other than the one originally making a recommendation for a proposed health care service to assess the medical necessity and appropriateness of the proposed health care service.
AC. "Voluntary second level review" means, for the purposes of this regulation, a request for a review of an adverse determination from a first-level appeal which is only available to persons covered under a group health coverage plan.
AD. "Stabilized" means, for the purposes of this regulation, with respect to an emergency medical condition or a life or limb threatening emergency, that no material deterioration of the condition is likely, within reasonable medical probability, to result or occur before an individual can be transferred.
AE. "Urgent care request" means, for the purposes of this regulation:
1. A request for a health care service or course of treatment with respect to which the time periods for making a non-urgent care request determination that:
a. Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or for a covered person with a physical or mental disability, creates an imminent and substantial limitation on his or her existing ability to live independently; or
b. In the opinion of a health care professional with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request.
2. Except as provided in section 4.AE.3., in determining whether a request is to be treated as an urgent care request, a person acting on behalf of the carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine.
3. Any request that a health care professional with knowledge of the covered person's medical condition determines and states is an urgent care request within the meaning of section 4.AE.1. shall be treated as an urgent care request.
AF. "Utilization review" means, for the purposes of this regulation, a set of formal techniques designed to monitor the use of, or evaluate the medical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques include ambulatory review, prospective review, second opinion, authorization, concurrent review, case management, discharge planning, and retrospective review. It also includes reviews for the purpose of determining coverage based on whether or not a procedure or treatment is considered experimental or investigational in a given circumstance, and reviews of a covered person's medical circumstances when necessary to determine if an exclusion applies in a given situation.

3 CCR 702-4-2-17-4

37 CR 11, June 10, 2014, effective 7/1/2014
37 CR 12, June 25, 2014, effective 7/15/2014
Colorado Register, Vol 37, No. 14. July 25, 2014, effective 8/15/2014
37 CR 23, December 10, 2014, effective 1/1/2015
38 CR 03, February 10, 2015, effective 3/15/2015
38 CR 06, March 25, 2015, effective 4/30/2015
38 CR 09, May 10, 2015, effective 6/1/2015
38 CR 13, July 10, 2015, effective 7/30/2015
38 CR 19, October 10, 2015, effective 11/1/2015
38 CR 21, November 10, 2015, effective 1/1/2016
38 CR 23, December 10, 2015, effective 1/1/2016
39 CR 01, January 10, 2016, effective 2/1/2016
39 CR 05, March 10, 2016, effective 4/1/2016
39 CR 08, April 25, 2016, effective 5/15/2016
39 CR 19, October 10, 2016, effective 11/1/2016
39 CR 20, October 25, 2016, effective 1/1/2017
39 CR 22, November 25, 2016, effective 1/1/2017
39 CR 23, December 10, 2016, effective 1/1/2017
39 CR 23, December 25, 2016, effective 1/1/2017
40 CR 03, February 10, 2017, effective 3/15/2017
40 CR 09, May 10, 2017, effective 6/1/2017
40 CR 15, August 10, 2017, effective 9/1/2017
40 CR 17, September 10, 2017, effective 10/1/2017
40 CR 21, November 10, 2017, effective 12/1/2017
41 CR 04, February 25, 2018, effective 4/1/2018
41 CR 05, March 10, 2018, effective 6/1/2018
41 CR 08, April 25, 2018, effective 6/1/2018
41 CR 09, May 10, 2018, effective 6/1/2018
41 CR 11, June 10, 2018, effective 7/1/2018
41 CR 15, August 10, 2018, effective 9/1/2018
41 CR 17, September 10, 2018, effective 10/1/2018
41 CR 18, September 25, 2018, effective 10/15/2018
41 CR 21, November 10, 2018, effective 12/1/2018
41 CR 23, December 10, 2018, effective 1/1/2019
42 CR 01, January 10, 2019, effective 2/1/2019
41 CR 19, October 10, 2018, effective 3/1/2019
42 CR 03, February 10, 2019, effective 4/1/2019
42 CR 04, February 25, 2019, effective 4/1/2019
42 CR 06, March 25, 2019, effective 6/1/2019
42 CR 08, April 10, 2019, effective 6/1/2019
42 CR 15, August 10, 2019, effective 9/1/2019
42 CR 17, September 10, 2019, effective 10/1/2019
43 CR 02, January 25, 2020, effective 12/20/2019
43 CR 02, January 25, 2020, effective 12/23/2019
42 CR 23, December 10, 2019, effective 1/1/2020
43 CR 01, January 10, 2020, effective 2/1/2020
42 CR 24, December 25, 2019, effective 2/2/2020
43 CR 06, March 25, 2020, effective 4/15/2020
43 CR 10, May 25, 2020, effective 8/1/2020
43 CR 14, July 25, 2020, effective 8/15/2020
43 CR 17, September 10, 2020, effective 10/1/2020
43 CR 18, September 25, 2020, effective 11/1/2020
43 CR 22, November 25, 2020, effective 12/15/2020
43 CR 24, December 25, 2020, effective 1/15/2021
44 CR 03, February 10, 2021, effective 3/15/2021
44 CR 08, April 25, 2021, effective 5/15/2021
44 CR 09, May 10, 2021, effective 6/1/2021
44 CR 10, May 25, 2021, effective 6/14/2021
44 CR 10, May 25, 2021, effective 6/15/2021
44 CR 13, July 10, 2021, effective 8/1/2021
44 CR 15, August 10, 2021, effective 9/1/2021
44 CR 19, October 10, 2021, effective 11/1/2021
44 CR 21, November 10, 2021, effective 12/1/2021
44 CR 23, December 10, 2021, effective 12/30/2021
44 CR 21, November 10, 2021, effective 1/1/2022
44 CR 23, December 10, 2021, effective 1/15/2022
44 CR 24, December 25, 2021, effective 1/15/2022
45 CR 03, February 10, 2022, effective 3/2/2022
45 CR 08, April 25, 2022, effective 5/30/2022
45 CR 09, May 10, 2022, effective 5/30/2022
45 CR 10, May 25, 2022, effective 6/14/2022
45 CR 11, June 10, 2022, effective 6/30/2022
45 CR 11, June 10, 2022, effective 7/15/2022
45 CR 19, October 10, 2022, effective 11/1/2022
45 CR 20, October 25, 2022, effective 11/14/2022
45 CR 21, November 10, 2022, effective 11/30/2022
45 CR 24, December 25, 2022, effective 1/14/2023
46 CR 01, January 10, 2023, effective 2/14/2023
46 CR 06, March 25, 2023, effective 2/15/2023
46 CR 03, February 10, 2022, effective 3/2/2023
46 CR 04, February 25, 2023, effective 3/17/2023
46 CR 05, March 10, 2023, effective 4/15/2023
46 CR 09, May 10, 2023, effective 5/30/2023
46 CR 09, May 10, 2023, effective 6/1/2023
46 CR 10, May 25, 2023, effective 6/15/2023
46 CR 11, June 10, 2023, effective 6/30/2023