3 Colo. Code Regs. § 702-4-4-5-4
Current through Register Vol. 48, No. 1, January 10, 2025
Section 3 CCR 702-4-4-5-4 - DefinitionsA. "Activities of daily living" mean, for the purposes of this regulation, bathing, continence, dressing, eating, toileting, and transferring.B. "Adverse determination" means, for the purposes of this regulation: 1. A determination by an insurer or its designee that a request for a pre-service or post-service benefit has been reviewed and, based upon the information provided, does not meet the insurer'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, and is therefore denied, reduced, or terminated;2. A denial for a benefit excluded by a long-term care policy 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; and/or3. A determination that the covered person has not met the necessary benefit trigger criteria.C. "Ambulatory review" means, for the purposes of this regulation, a utilization review of health care services performed or provided in an outpatient setting.D. "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.E. "Benefit trigger" means, for the purposes of this regulation, a contractual provision in the covered person's long-term care insurance policy conditioning the payment of benefits on a determination of the covered person's ability to perform activities of daily living; on cognitive impairment; or, for tax-qualified long-term care policies, that the covered person is a chronically ill individual.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. "Chronically ill individual" means, for the purposes of this regulation, any individual who has been certified by a licensed health care professional as:1. Being unable to perform, without substantial assistance from another individual, at least two (2) activities of daily living for a period of at least ninety (90) days due to a loss of functional capacity; or2. Requiring substantial supervision to protect such individual from threats to health and safety due to severe cognitive impairment.H. "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 or treatment under review.I. "Complaint" means, for the purposes of this regulation, a written communication primarily expressing a grievance.J. "Covered person" shall have the same meaning as found at § 10-16-102(15), C.R.S.K. "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 insurer.L. "Designated representative" means, for the purposes of this regulation: 1. A person, including the treating health care professional or a person authorized by section 4.L.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;3. In the case of an urgent care request, a health care professional with knowledge of the covered person's medical condition; and/or4. A family member of the covered person or the covered person's treating health care professional only when the covered person is unable to provide consent.M. "Discharge planning" means, for the purposes of this regulation, the formal process for determining, prior to discharge from a facility or service, the coordination and management of the care that a covered person receives following discharge from a facility.N. "Facility" means, for the purposes of this regulation, a facility licensed or otherwise authorized to furnish health or long-term care services.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. "Insurer's receipt" means, for the purposes of this regulation, the receipt date as date-stamped by the insurer 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 insurer's receipt date.S. "Long-term care insurance" shall have the same meaning as found at § 10-19-103(5), C.R.S. For the purposes of this regulation, it includes the term "long-term care policy".T. "Medical professional" means, for the purposes of this regulation, an individual licensed pursuant to the "Colorado Medical Practice Act", article 36 of title 12, C.R.S.U. "Prospective review" means, for the purposes of this regulation, a utilization review conducted prior to an admission or course of treatment. Also known as a "pre-service review".V. "Retrospective review" means, 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. Also known as a "post-service review".W. "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 long-term care policy.X. "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 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 this or her existing ability to live independently.2. Except as provided in section 4.X.3., in determining whether a request is to be treated as an urgent care request, a person acting on behalf of the insurer shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine.3. Any request that a physician with knowledge of the covered person's medical condition determines and states is an urgent care request within the meaning of section 4.X.1. shall be treated as an urgent care request.Y. "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 or settings. Techniques include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, and retrospective review. It also includes reviews of a covered person's medical circumstances when necessary to determine if a policy exclusion applies in a given situation.37 CR 11, June 10, 2014, effective 7/1/201437 CR 12, June 25, 2014, effective 7/15/2014Colorado Register, Vol 37, No. 14. July 25, 2014, effective 8/15/201437 CR 23, December 10, 2014, effective 1/1/201538 CR 03, February 10, 2015, effective 3/15/201538 CR 06, March 25, 2015, effective 4/30/201538 CR 09, May 10, 2015, effective 6/1/201538 CR 13, July 10, 2015, effective 7/30/201538 CR 19, October 10, 2015, effective 11/1/201538 CR 21, November 10, 2015, effective 1/1/201638 CR 23, December 10, 2015, effective 1/1/201639 CR 01, January 10, 2016, effective 2/1/201639 CR 05, March 10, 2016, effective 4/1/201639 CR 08, April 25, 2016, effective 5/15/201639 CR 19, October 10, 2016, effective 11/1/201639 CR 20, October 25, 2016, effective 1/1/201739 CR 22, November 25, 2016, effective 1/1/201739 CR 23, December 10, 2016, effective 1/1/201739 CR 23, December 25, 2016, effective 1/1/201740 CR 03, February 10, 2017, effective 3/15/201740 CR 09, May 10, 2017, effective 6/1/201740 CR 15, August 10, 2017, effective 9/1/201740 CR 17, September 10, 2017, effective 10/1/201740 CR 21, November 10, 2017, effective 12/1/201741 CR 04, February 25, 2018, effective 4/1/201841 CR 05, March 10, 2018, effective 6/1/201841 CR 08, April 25, 2018, effective 6/1/201841 CR 09, May 10, 2018, effective 6/1/201841 CR 11, June 10, 2018, effective 7/1/201841 CR 15, August 10, 2018, effective 9/1/201841 CR 17, September 10, 2018, effective 10/1/201841 CR 18, September 25, 2018, effective 10/15/201841 CR 21, November 10, 2018, effective 12/1/201841 CR 23, December 10, 2018, effective 1/1/201942 CR 01, January 10, 2019, effective 2/1/201941 CR 19, October 10, 2018, effective 3/1/201942 CR 03, February 10, 2019, effective 4/1/201942 CR 04, February 25, 2019, effective 4/1/201942 CR 06, March 25, 2019, effective 6/1/201942 CR 08, April 10, 2019, effective 6/1/201942 CR 15, August 10, 2019, effective 9/1/201942 CR 17, September 10, 2019, effective 10/1/201943 CR 02, January 25, 2020, effective 12/20/201943 CR 02, January 25, 2020, effective 12/23/201942 CR 23, December 10, 2019, effective 1/1/202043 CR 01, January 10, 2020, effective 2/1/202042 CR 24, December 25, 2019, effective 2/2/202043 CR 06, March 25, 2020, effective 4/15/202043 CR 10, May 25, 2020, effective 8/1/202043 CR 14, July 25, 2020, effective 8/15/202043 CR 17, September 10, 2020, effective 10/1/202043 CR 18, September 25, 2020, effective 11/1/202043 CR 22, November 25, 2020, effective 12/15/202043 CR 24, December 25, 2020, effective 1/15/202144 CR 03, February 10, 2021, effective 3/15/202144 CR 08, April 25, 2021, effective 5/15/202144 CR 09, May 10, 2021, effective 6/1/202144 CR 10, May 25, 2021, effective 6/14/202144 CR 10, May 25, 2021, effective 6/15/202144 CR 13, July 10, 2021, effective 8/1/202144 CR 15, August 10, 2021, effective 9/1/202144 CR 19, October 10, 2021, effective 11/1/202144 CR 21, November 10, 2021, effective 12/1/202144 CR 23, December 10, 2021, effective 12/30/202144 CR 21, November 10, 2021, effective 1/1/202244 CR 23, December 10, 2021, effective 1/15/202244 CR 24, December 25, 2021, effective 1/15/202245 CR 03, February 10, 2022, effective 3/2/202245 CR 08, April 25, 2022, effective 5/30/202245 CR 09, May 10, 2022, effective 5/30/202245 CR 10, May 25, 2022, effective 6/14/202245 CR 11, June 10, 2022, effective 6/30/202245 CR 11, June 10, 2022, effective 7/15/202245 CR 19, October 10, 2022, effective 11/1/202245 CR 20, October 25, 2022, effective 11/14/202245 CR 21, November 10, 2022, effective 11/30/202245 CR 24, December 25, 2022, effective 1/14/202346 CR 01, January 10, 2023, effective 2/14/202346 CR 06, March 25, 2023, effective 2/15/202346 CR 03, February 10, 2022, effective 3/2/202346 CR 04, February 25, 2023, effective 3/17/202346 CR 05, March 10, 2023, effective 4/15/202346 CR 09, May 10, 2023, effective 5/30/202346 CR 09, May 10, 2023, effective 6/1/202346 CR 10, May 25, 2023, effective 6/15/202346 CR 11, June 10, 2023, effective 6/30/2023