3 Colo. Code Regs. § 702-4-2-15-5

Current through Register Vol. 47, No. 24, December 25, 2024
Section 3 CCR 702-4-2-15-5 - Rules
A. Every contract between a carrier that has covered lives in Colorado and a provider or its representative that concerns the delivery, provision, payment or offering of care or services covered by a managed care plan that is issued, renewed, amended or extended shall contain provisions substantially similar to the following:
1. "No individual or group of providers covered by this contract shall be prohibited from protesting or expressing disagreement with a medical decision, medical practice of [name of carrier] or an entity representing or working for the carrier (e.g., a utilization review company)."
2. "[Name of carrier] or an entity representing or working for the carrier shall not be prohibited from protesting or expressing disagreement with a medical decision, medical policy, or medical practice of an individual or group or providers covered by this contract."
3. "[Name of carrier] shall not terminate this contract because a provider covered by this contract expresses disagreement with a decision by [name of carrier] or an entity representing or working for such carrier to deny or limit benefits to a covered person or because the provider discusses with a current, former or prospective patient any aspect of the patient's medical condition, any proposed treatments or treatment alternatives, whether covered by the plan or not, policy provisions or a plan, or a provider's personal recommendation regarding selection of a health plan based upon the provider's personal knowledge of the health needs of such patients."
B. Every contract between a carrier and an intermediary that concerns the delivery, provision, payment or offering of care or services covered by a managed care plan that is issued, renewed, amended or extended shall contain a provision requiring that the underlying contract authorizing the intermediary to negotiate and execute contracts with carriers, on behalf of providers, contain provisions substantially similar to the following:
1. "No individual or group of providers covered by any contract executed by [name of intermediary] shall be prohibited from protesting or expressing disagreement with a medical decision, medical policy or medical practice of the carrier or an entity representing or working for such carrier (e.g. a utilization review company);"
2. "The carrier or an entity representing or working for such carrier shall not be prohibited from protesting or expressing disagreement with a medical decision, medical policy or medical practice of an individual or group of providers covered by any contract executed by [name of intermediary];"
3. "The carrier shall not terminate any contract executed by [name of intermediary] because any individual or group of providers covered by the contract:
a. Expresses disagreement with a decision by the carrier or an entity representing or working for such carrier to deny or limit benefits to a covered person,
b. Assists the covered person to seek reconsideration for the carrier's decision, or
c. Discusses with a current, former or prospective patient any aspect of the patient's medical condition, any proposed treatments or treatment alternatives, whether covered by the plan or not, policy provisions of a plan, or a provider's personal recommendation regarding selection of a health plan based on the provider's personal knowledge of the needs of such patients."
C. Any contract entered into by a carrier with one or more intermediaries to conduct utilization management, utilization reviews, provider credentialing, administration of health insurance benefits, setting or negotiation of reimbursement rates, payment to providers, network development, or disease management programs, when issued, renewed, amended or extended shall contain provisions requiring the intermediary to:
1. Comply with the same standards, guidelines, medical policies, and benefit terms of the carrier; and
2. Indicate the name of the intermediary and the name of the carrier for which it is conducting the work when making any payment to a health care provider on behalf of the carrier.

3 CCR 702-4-2-15-5

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