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 4-2 - LIFE, ACCIDENT AND HEALTH, Series 4-2 Accident and Health (General)
Regulation Regulation 4-2-17 - PROMPT INVESTIGATION OF HEALTH CLAIMS INVOLVING UTILIZATION REVIEW AND DENIAL OF BENEFITS AND RULES RELATED TO INTERNAL CLAIMS AND APPEALS PROCESSES
Section 3 CCR 702-4-2-17-13 - Expedited Review of an Adverse Determination

3 Colo. Code Regs. § 702-4-2-17-13

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Current through Register Vol. 47, No. 24, December 25, 2024
Section 3 CCR 702-4-2-17-13 - Expedited Review of an Adverse Determination
A. A carrier shall establish written procedures in compliance with all of the requirements of this section for the expedited review of urgent care requests or grievances involving an adverse determination. A carrier shall also provide an expedited review for a request for a benefit for a covered person who has received emergency services but has not been discharged from a medical facility. The procedures shall allow a covered person to request an expedited review under this section orally or in writing. The procedures shall also allow the covered person to identify a medical facility and health care professional(s) to whom the carrier shall send a copy of the review decision. Pursuant to § 10-16-113.5(7), C.R.S., a covered person requesting an expedited external review may request such review concurrently with a request for an expedited internal review.
B. An expedited review shall be available to, and may be initiated by, the covered person or the medical facility and/or health care professional acting on behalf of the covered person. For purposes of this section, "covered person" includes the designated representative of a covered person.
C. Pursuant to § 10-3-1104(1)(i), C.R.S., all written requests for an expedited review shall be entered into the carrier's complaint record.
D. Expedited appeal evaluations.
1. Expedited appeals shall be evaluated by an appropriate clinical peer(s) in the same or similar specialty as would typically manage the case under review. For the purposes of this section, the clinical peer(s) shall be called "the reviewer(s)". The clinical peer(s) shall not have been involved in the initial adverse determination.
2. In conducting a review under this section, the reviewer(s) shall take into consideration all comments, documents, records, and other information regarding the request for services submitted by, or on behalf of, the covered person without regard to whether the information was submitted or considered in making the initial adverse determination.
E. Covered person's rights. A covered person does not have the right to attend or to have a representative in attendance at the expedited review, but the covered person is entitled to:
1. Submit written comments, documents, records, and other materials relating to the request for benefits for the reviewer(s) to consider when conducting the review; and
2. Receive from the carrier, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the covered person's request for benefits, as described in section 11.D.2.
F. In an expedited review, all necessary information, including the carrier's decision, shall be transmitted between the carrier and the covered person or the medical facility and/or health care professional acting on behalf of the covered person by telephone, facsimile or similar expeditious method available.
G. In an expedited review, a carrier shall make a decision and notify the covered person or the medical facility and/or health care professional acting on the covered person's behalf as expeditiously as the covered person's medical condition requires, but in no event more than seventy-two (72) hours after the carrier's receipt of the request. If the expedited review is a concurrent review and an adverse determination is made, the health care service or treatment 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.
H. A carrier shall provide a written confirmation of its decision concerning an expedited review within three (3) calendar days of providing notification of that decision, if the initial notification was not in writing.
I. In the case of an adverse determination, the written decision shall comply with the requirements specified in sections 11.G. and 11.H. of this regulation.
J. For purposes of calculating the time periods within which a decision is required to be made under section 13.G., the time period within which the decision is required to be made shall begin on the date of the carrier's receipt of the request in accordance with the carrier's procedures for filing a request without regard to whether all of the information necessary to make the determination accompanies the request.
K. In any case where the expedited review process does not resolve a difference of opinion between the carrier and the covered person or the medical facility and/or health care professional acting on behalf of the covered person, the covered person or the medical facility and/or health care professional acting on behalf of the covered person may request an independent external review.
L. Retrospective adverse determinations are not eligible for the expedited review process.

3 CCR 702-4-2-17-13

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