3 Colo. Code Regs. § 702-4-2-17-7

Current through Register Vol. 47, No. 24, December 25, 2024

Section 3 CCR 702-4-2-17-7 - Standard Utilization Review

A. A carrier shall establish written procedures in compliance with all of the requirements of this section for:

1. Reviewing prospective benefit requests received from a covered person, medical facility or a health care professional; and

2. Making and notifying the covered person, medical facility or the health care professional, as applicable, of utilization review decisions with respect to non-urgent benefit requests.

B. Prospective utilization review determinations.

1. Time period for determination and notification.

a. Subject to section 7.B.1.b., a carrier shall make the determination and notify the covered person and the covered person's medical facility or health care professional of the determination, whether the carrier certifies the provision of the benefit or not, within a reasonable period of time appropriate to the covered person's medical condition, but in no event later than fifteen (15) calendar days after the carrier's receipt of the request. Whenever the determination is an adverse determination, the carrier shall make the notification of the adverse determination in accordance with section 7.E.

b. The time period for making a determination and notifying the covered person of the determination pursuant to section 7.B.1.a. may be extended one (1) time by the carrier for up to fifteen (15) calendar days, provided the carrier:

(1) Determines that an extension is necessary due to matters beyond the carrier's control; and

(2) Notifies the covered person, prior to the expiration of the initial fifteen (15) calendar day time period, of the circumstances requiring the extension of time and the date by which the carrier expects to make a determination.

c. If the extension under section 7.B.1.b. is necessary due to the failure of the covered person to submit information necessary to reach a determination on the request, the notice of extension shall:

(1) Specifically describe the required information necessary to complete the request; and

(2) Give the covered person at least forty-five (45) calendar days from the date of receipt of a notice to provide the specified information. If the deadline for submitting the specified information ends on a weekend or holiday, the deadline will be extended to the next business day.

d. All coverage determinations shall include:

(1) A review of the covered person's eligibility; and

(2) A review of the applicability of the health coverage plan's benefits, limitations and exclusions.

e. The authorization notice shall state that the service(s) and treatment(s) which are the subject of the standard utilization review request are covered services, subject to all of the terms and conditions of the policy, as long as:

(1) The covered person is still covered by the health coverage plan at the time the service(s) and treatment(s) are provided;

(2) The health care professional(s) and medical facility(ies) performing the authorized services are part of the carrier's network at the time of service unless otherwise specifically authorized; and

(3) Benefit limitations, such as annual visit or monetary limitations, which may apply to the approved service(s) and treatment(s) have not been exhausted.

f. Carriers may include beginning/end dates or the length of time the authorization is effective appropriate to the type of service being pre-authorized provided that they do not unnecessarily restrict the covered person's ability to schedule the services.

2. Failure to meet the carrier's filing procedures.

a. Whenever the carrier receives a prospective review request from a covered person that fails to meet the carrier's filing procedures, the carrier shall notify the covered person of this failure and provide in the notice information on the proper procedures to be followed for filing a request.

b. Required notice.

(1) The notice required under section 7.B.2.a. shall be provided as soon as possible, but in no event later than five (5) calendar days following the date of the failure.

(2) The carrier shall provide the notice in writing.

c. The provisions of section 7.B.2. shall apply only in the case of a failure that:

(1) Is a communication by a covered person that is received by a person or organizational unit of the carrier responsible for handling benefit matters; and

(2) Is a communication that refers to a specific covered person, a specific medical condition or symptom, and a specific health care service, treatment or medical facility and/or health care professional for which authorization is being requested.

3. For an adverse determination regarding a prospective review decision that occurs during a covered person's hospital stay or course of treatment, also known as concurrent review, the health care service or treatment that is the subject of an adverse determination shall continue to be covered according to the provisions of the health coverage plan until the covered person has been notified of the determination by the carrier.

4. The requirements of section 7.B. apply to all written requests involving utilization review received by the carrier which are submitted by a covered person or a medical facility and/or health care professional requesting a determination of coverage for a specific health care service or treatment for the covered person.

C. Retrospective utilization review determinations.

1. For retrospective utilization review determinations, a carrier shall make the determination and notify the covered person and the covered person's medical facility and/or health care professional of the determination within a reasonable period of time, but in no event later than thirty (30) calendar days after the carrier's receipt of the benefit request. Whenever the determination is an adverse determination, the carrier shall provide notice of the adverse determination to the covered person in accordance with section 7.E.

2. Time period for determination and notification.

a. The time period for making a determination and notifying the covered person of the determination pursuant to section 7.C.1. may be extended one (1) time by the carrier for up to fifteen (15) calendar days, provided the carrier:

(1) Determines that an extension is necessary due to matters beyond the carrier's control; and

(2) Notifies the covered person, prior to the expiration of the initial thirty (30) calendar day time period, of the circumstances requiring the extension of time and the date by which the carrier expects to make a determination.

b. If the extension under section 7.C.2.a. is necessary due to the failure of the covered person to submit information necessary to reach a determination on the request, the notice of extension shall:

(1) Specifically describe the required information necessary to complete the request; and

D. Calculation of time periods.

1. For purposes of calculating the time periods within which a determination is required to be made under sections 7.B. and 7.C., the time period shall begin on the date of the carrier's receipt of the request in accordance with the carrier's procedures for filing a request without regard to whether all of the information necessary to make the determination accompanies the request.

2. Extensions.

a. If the time period for making the determination under sections 7.B. or 7.C. is extended due to the covered person's failure to submit the information necessary to make the determination, the time period for making the determination shall be tolled from the date on which the carrier sends the notification of the extension to the covered person until the earlier of:

(1) The date on which the covered person responds to the request for additional information; or

(2) The date on which the specified information was to have been submitted.

b. If the covered person fails to submit the information before the end of the period of the extension, as specified in sections 7.B. or 7.C., the carrier may deny the authorization of the requested benefit.

E. Requirements for adverse determination notifications.

1. Except for the adverse determinations described section 7.E.2., a notification of an adverse determination under this section shall, in a manner calculated to be understood by the covered person, set forth:

a. An explanation of the specific medical basis for the adverse determination;

b. The specific reason or reasons for the adverse determination;

c. Reference to the specific plan provisions on which the determination is based;

d. A description of any additional material or information necessary for the covered person to perfect the benefit request, including an explanation of why the material or information is necessary to perfect the request;

e. If the carrier relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that a specific rule, guideline, protocol, or other similar criterion was relied upon to make the adverse determination and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the covered person upon request;

f. If the adverse determination is based on a medical necessity, experimental or investigational treatment, or similar exclusion or limitation, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the health coverage plan to the covered person's medical circumstances or a statement that an explanation will be provided to the covered person free of charge upon request;

g. Information sufficient for the covered person to be able to identify the claim involved and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning;

h. If applicable, instructions for requesting:

(1) A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination, as provided in section 7.E.1.e.;

(2) The written statement of the scientific or clinical rationale for the adverse determination, as provided in section 7.E.1.f.; and/or

(3) The information necessary to identify the claim, as provided in section 7.E.1.g.;

i. A description of the carrier's review procedures and the time limits applicable to such procedures; and

j. An explanation of the right of the covered person to appeal an initial adverse determination with a description of the procedures for requesting an appeal.

(1) For individual health coverage plans, the notice shall include:

(a) An explanation of the right to a single level of internal appeal through a written appeal review or, unless it is an expedited appeal, the ability to appear in person or by telephone conference at a review meeting; and

(b) A description of the process to schedule a review meeting including the covered person's rights pursuant to section 12.

(2) For group health coverage plans, the notice shall advise that the covered person does not have the right to be present during the first level review.

2. For denials based on a contractual exclusion, the adverse determination notice shall include the health coverage plan's specific exclusion language and shall advise the covered person of the right to appeal the applicability of the exclusion by providing evidence from a medical professional that there is a reasonable medical basis that the contractual exclusion does not apply.

3. A carrier shall provide the notice required under this section in writing, either on paper or electronically.

4. All written adverse determinations, except an adverse determination described in § 10-16-113(1)(b)(I)(C) and (E), C.R.S., shall be reviewed and signed by a licensed physician familiar with standards of care in Colorado. In the case of written denials of requests for covered benefits for dental care, a licensed dentist familiar with standards of care in Colorado may review and sign the written denial. Initial adverse determination notifications provided on an explanation of benefits form (EOB) are exempt from this requirement.

5. The notice of the initial adverse determination shall include information concerning the covered person's ability to request an internal and external expedited review on a concurrent basis. This information may be included in the letter or other notice advising the covered person of the finding of an adverse determination, or it may be included as a separate document within the same mailing.

F. Applicability.

1. The requirements of section 7 apply to all written requests involving standard utilization prospective reviews received by the carrier which are submitted by covered person, designated representative, a medical facility, and/or a health care professional requesting a determination of coverage for a specific health care service or treatment for the covered person.

2. Carriers' Requirements for Non-Urgent Prior Authorization Requests.

a. Time period for determination and notification.

(1) Carriers shall notify the medical facility or health care professional, as applicable, and the covered person within five (5) business days after the carrier's receipt of the request, that the request is approved, denied, or incomplete.

(2) If the request is incomplete, the carrier shall indicate the specific additional information consistent with the requirements of §§ 10-16-112.5(2)(a) and 10-16-112.5(4)(a)(III), C.R.S., required to process the request.

(a) The medical facility or health care professional, as applicable, shall submit the additional information within two (2) business days after receipt of the request for additional information. If the medical facility or health care professional, as applicable, fails to submit the required additional information, the prior authorization is not deemed granted.

(b) If additional information pursuant to the requirements of § 10-16-112.5(4)(a)(III), C.R.S., is required from the covered person, carriers shall give him or her at least forty-five (45) calendar days from the date of receipt of the notice to provide the specified information. If the deadline for submitting the specified information ends on a weekend or holiday, the deadline will be extended to the next business day.

(i) Carriers shall notify the medical facility or health care professional, as applicable, that the covered person has additional time to submit the required information.

(ii) The prior authorization request will not be deemed as granted during this time period.

(3) Carriers shall notify the medical facility or health care professional, as applicable, and the covered person that the request is approved or denied within five (5) business days after the carrier's receipt of the additional information required pursuant to section 7. F.2.a.(2) or the end of time period specified in section 7.F.2.a.(2)(b).

(4) The prior authorization request is deemed granted if a carrier fails to provide the notification as required by section 7.F.2.a.(1). except as provided in section 7.F.2.a.(2)(b). Carriers shall assign a unique authorization number to be utilized by the medical facility or health care professional, as applicable, for claim submission for a prior authorization that is deemed granted pursuant to this Section 7.F.2.a.(4).

b. Approval of the prior authorization request.

(1) All approvals shall include:

(a) A review of the covered person's eligibility; and

(b) A review of the applicability of the health coverage plan's benefits, limitations and exclusions; and

(c) A unique prior authorization number attributable to the request.

(2) The approval shall state that the service(s) and treatment(s) which are the subject of the prior approval request are covered services as long as the covered person is still covered by the same health coverage plan at the time the service(s) and treatment(s) are provided and shall include applicable requirements, if any, to use contracted medical facilities and health care professionals unless otherwise specifically authorized. The notice shall also reference any benefit limitations, such as annual visit or monetary limitations, which may apply to the approved service(s) and treatment(s).

c. Denial of the prior authorization request.

(1) If the carrier denies the prior authorization request, it shall comply with the requirements of section 7.E. as applicable;

(2) The carrier shall include information concerning any alternative treatment, test, procedure, or medication it requires; and

(3) The carrier shall assign and provide a unique prior authorization number attributable to the request as required by § 10-16-112.5(3)(c)(I), C.R.S.

(4) Section 7.F.2.c.(2) applies to prior authorization requests for drug benefits subject to § 10-16-124.5, C.R.S.

d. Upon approval, a prior authorization is valid for at least 180 days after the date of approval and continues for the duration of the authorized course of treatment unless:

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

(2) The medical facility or health care professional, as applicable, never performed the services that were requested;

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

(4) The person receiving the service is no longer covered by the health coverage plan on or before the date the service was delivered; or

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

e. A change in a carrier's coverage or approval criteria for a previously approved health care service does not affect a covered person who received a prior authorization before the effective date of the change for the remainder of the covered person's plan year.

3 CCR 702-4-2-17-7

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