3 Colo. Code Regs. § 702-4-2-17-8

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

Section 3 CCR 702-4-2-17-8 - Expedited Utilization Review

A. Procedures.

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

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

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

For the purposes of Section 8, "covered person" includes the designated representative of a covered person.

2. Notification requirements.

a. As part of the procedures required under section 8.A.1., a carrier shall provide that, in the case of a failure by a covered person to follow the carrier's procedures for filing an urgent care request, the covered person shall be notified of the failure and the proper procedures to be followed for filing the request.

b. The notice required under section 8.A.2.a.:

(1) Shall be provided to the covered person as soon as possible but not later than twenty-four (24) hours after the carrier's receipt of the request; and

(2) Shall be in writing.

c. The provisions of section 8.A.2. 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 approval is being requested.

B. Urgent care requests.

1. Notification requirements for carrier determinations.

a. For an urgent care request, unless the covered person has failed to provide sufficient information for the carrier to determine whether, or to what extent, the benefits requested are covered benefits or payable under the covered person's health coverage plan, the carrier shall notify the covered person and the covered person's medical facility and health care professional of the carrier's determination with respect to the request, whether or not the determination is an adverse determination, as soon as possible, taking into account the medical condition of the covered person, but in no event later than seventy-two (72) hours after the carrier's receipt of the request.

b. If the carrier's determination is an adverse determination, the carrier shall provide notice of the adverse determination in accordance with section 8.E.

c. 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.

d. The authorization notice shall state that the service(s) and treatment(s) which are the subject of the urgent 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.

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

2. Notification requirements for insufficient information.

a. If the covered person fails to provide sufficient information for the carrier to make a determination, the carrier shall notify the covered person either orally or, if requested by the covered person, in writing of this failure and state what specific information is needed as soon as possible, but in no event later than twenty-four (24) hours after the carrier's receipt of the request.

b. The carrier shall provide the covered person a reasonable period of time to submit the necessary information, taking into account the circumstances, but in no event less than forty-eight (48) hours after notifying the covered person of the failure to submit sufficient information, as provided in section 8.B.2.a.

c. The carrier shall notify the covered person and the covered person's medical facility and health care professional of its determination with respect to the urgent care request as soon as possible, but in no event more than forty-eight (48) hours after the earlier of:

(1) The carrier's receipt of the requested specified information; or

(2) The end of the period provided for the covered person to submit the requested specified information.

d. If the covered person fails to submit the information before the end of the period of the extension, as specified in section 8.B.2.b., the carrier may deny the authorization of the requested benefit.

e. If the carrier's determination is an adverse determination, the carrier shall provide notice of the adverse determination in accordance with section 8.E.

C. Concurrent urgent care review requests.

1. For concurrent urgent care review requests involving a request by the covered person to extend the course of treatment beyond the initial period of time or the number of treatments authorized, if the request is made at least twenty-four (24) hours prior to the expiration of the authorized period of time or authorized number of treatments, the carrier shall make a determination with respect to the request and notify the covered person and the covered person's medical facility or health care professional of the determination, whether it is an adverse determination or not, as soon as possible, taking into account the covered person's medical condition, but in no event more than twenty-four (24) hours after the carrier's receipt of the request.

2. If the carrier's determination is an adverse determination, the carrier shall provide notice of the adverse determination in accordance with section 8.E. 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.

D. For purposes of calculating the time periods within which a determination is required to be made under sections 8.B. or 8.C., the time period shall begin on the date of the carrier's receipt of the request in accordance with the carrier's procedures established for filing a request without regard to whether all of the information necessary to make the determination accompanies the request.

E. Adverse determination notification requirements.

1. 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 reasons 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;

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 8.E.1.e.;

(2) The written statement of the scientific or clinical rationale for the adverse determination, as provided in section 8.E.1.f.; and/or

(3) The information necessary to identify the claim, as provided in section 8.E.1.g.;

i. A description of the carrier's expedited 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 an explanation of the right to a single level of internal appeal through a written appeal review and, because it is an expedited appeal, the inability to appear in person or by telephone conference at a review meeting.

(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. Additional notification requirements.

a. A carrier may provide the notice required under this section orally, in writing, or electronically.

b. If notice of the adverse determination is provided orally, the carrier shall provide a written or electronic notice of the adverse determination within three (3) calendar days following the oral notification.

3. All written adverse determinations 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.

4. 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 8 apply to all written requests involving expedited utilization prospective reviews received by the carrier which are submitted by a covered person, designated representative, a medical facility, 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 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 two (2) business days but not longer than seventy-two (72) hours 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 with 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-eight (48) hours from the date of receipt of the notice to provide the specified information.

(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 forty-eight (48) hours after the carrier's receipt of the additional information required pursuant to section 8.F.2.a.(2) or the end of time period specified in section 8.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 8.F.2.a.(1) except as provided in section 8.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 8.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;

(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 8.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 8.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 as long as the service(s) and treatment(s) are obtained from a contracted medical facility or health care professional, as applicable.

3 CCR 702-4-2-17-8

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