Section 10-16-112 - Private utilization review - health-care coverage entity responsibility - definitions(1) As used in this section, unless the context otherwise requires: (a) "Private utilization review organization" means an entity, other than a hospital or public reviewer following federal guidelines, that conducts utilization review or reviews and makes determinations on prior authorization requests for health-care services as described in section 10-16-112.5. This definition shall not apply to any independent medical examination provided for in any policy of insurance.(b) "Utilization review" means an evaluation of the necessity, appropriateness, and efficiency of the use of health-care services, procedures, and facilities, but does not include any independent medical examination provided for in any policy of insurance.(2) Any private utilization review organization providing services to an insurance carrier, nonprofit hospital and health-care service corporation, or health maintenance organization regulated pursuant to the provisions of this article is the direct representative of the insurance carrier, nonprofit hospital and health-care service corporation, or health maintenance organization. Any insurance carrier, nonprofit hospital and health-care service corporation, or health maintenance organization is responsible for the actions of any private utilization review organization acting within the scope of any contract and on its behalf within the scope of any contract which result in any violation of this title or any rules or regulations promulgated by the commissioner.Amended by 2019 Ch. 165,§ 3, eff. 8/2/2019 and applicable to prior authorization requests for health care services submitted on or after 1/1/2020.L. 93: Entire section added, p. 494, § 2, effective April 26.Section 4 of chapter 165 (HB 19-1211), Session Laws of Colorado 2019, provides that the act changing this section applies to prior authorization requests for health care services submitted on or after August 2, 2019.
For the legislative declaration in HB 19-1211, see section 1 of chapter 165, Session Laws of Colorado 2019.