Request for Comment on DRAFT Proposed Amended Regulation 4-2-17 - Investigation of Health Claims Involving Utilization Review and Denial of Benefits and Rules Related to the Appeals Processes

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The Division is seeking comments on the following UPDATED draft proposed new regulation:

DRAFT Proposed Amended 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


The purpose of this regulation is to set forth guidelines for carrier compliance with the provisions of §§ 10-3-1104(1)(h), 10-16-409(1)(a), and 10-16-113, C.R.S., in situations involving utilization review and certain denials of benefits for treatment, as well as rescission, cancellation, or denial of coverage based on an eligibility determination, as described herein. Among other things, § 10-3-1104(1)(h), C.R.S., requires carriers to adopt and implement reasonable standards for the prompt investigation of claims arising from health coverage plans; promptly provide a reasonable explanation of the basis in the health coverage plan in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement; and refrain from denying a claim without conducting a reasonable investigation based upon all available information.

This regulation is designed to provide minimum standards for handling appeals and grievances involving utilization review determinations, certain denials of benefits for treatments excluded by health coverage plans, and as otherwise required by § 10-16-113, C.R.S.

Regulation is being amended to make changes identified by Legislative Council during their review of the regulation.

The Division is requesting informal comments be submitted to DORA_INS_RulesandRecords@state.co.us no later than 5 PM, November 27, 2020.

This draft regulation, as well as other draft regulations currently released for informal public comment, can be found on our page for Draft Regulations and Bulletins for Informal Comments

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