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 4-4 - LIFE, ACCIDENT AND HEALTH, Series 4-4 Long Term Care
Regulation Regulation 4-4-5 - PROMPT INVESTIGATION OF LONG-TERM CARE INSURANCE CLAIMS INVOLVING UTILIZATION REVIEW AND DENIAL OF BENEFITS AND RULES RELATED TO INTERNAL CLAIMS AND APPEALS PROCESSES
Section 3 CCR 702-4-4-5-7 - Standard Utilization Review

3 Colo. Code Regs. § 702-4-4-5-7

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Current through Register Vol. 48, No. 1, January 10, 2025
Section 3 CCR 702-4-4-5-7 - Standard Utilization Review
A. An insurer shall maintain written procedures pursuant to this section for making utilization review decisions and for notifying covered persons of its decisions. For purposes of this section, "covered person" includes the designated representative of a covered person.
B. Prospective review determinations.
1. Time period for determination and notification.
a. Subject to section 7.B.1.b., an insurer shall make the determination and notify the covered person and the covered person's facility and/or health care professional of the determination, whether the insurer 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 insurer's receipt of the request. Whenever the determination is an adverse determination, the insurer 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 insurer for up to fifteen (15) calendar days, provided the insurer:
(1) Determines that an extension is necessary due to matters beyond the insurer'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 insurer 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 shall be extended to the next business day.
2. Failure to meet the insurer's filing procedures.
a. Whenever the insurer receives a prospective review request from a covered person that fails to meet the insurer's filing procedures, the insurer 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 insurer 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 insurer responsible for handling benefit matters; and
(2) Is a communication that refers to a specific covered person, a specific medical condition, and a specific health care service, treatment or 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 facility stay or course of treatment, also known as concurrent review, the health care service that is the subject of an adverse determination shall continue to be covered according to the provisions of the long-term care policy until the covered person has been notified of the determination by the insurer.
4. The requirements of section 7.B. apply to all written requests involving utilization review received by the insurer which are submitted by a covered person or a facility and/or health care professional requesting a determination of coverage for a specific health care service for the covered person.
C. Retrospective review determinations.
1. For retrospective review determinations, an insurer shall make the determination and notify the covered person and the covered person's 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 insurer's receipt of the benefit request. Whenever the determination is an adverse determination, the insurer 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 insurer for up to fifteen (15) calendar days, provided the insurer:
(1) Determines that an extension is necessary due to matters beyond the insurer'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 insurer 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
(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 shall be extended to the next business day.
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 insurer's receipt of the request in accordance with the insurer'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 insurer 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 insurer 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 policy 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 insurer 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 or similar exclusion or limitation, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the long-term care policy 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 insurer'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 long-term care policies, 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 11.
(2) For group long-term care policies, 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 long-term care policy'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. An insurer shall provide the notice required under this section in writing, either on paper or electronically.
4. All written adverse determinations subject to the requirements of this regulation shall be reviewed and signed by a licensed physician familiar with standards of care in Colorado.
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. The requirements of section 7 apply to all written requests involving standard utilization review received by the insurer which are submitted by a covered person or a facility and/or health care professional requesting a determination of coverage for a specific health care service for the covered person.

3 CCR 702-4-4-5-7

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