Commercial Insurance Resources for Behavioral Health Providers in Colorado

This is an umbrella term used by the Division to refer to any professionally licensed or certified provider who has the ability to provide reimbursable behavioral health services (or care) through commercial health insurance in Colorado. This generally includes, but is not limited to, Psychiatrists, Addiction Medicine Doctors, Advanced Practice Registered Nurses, Clinical Nurse Specialists, Psychiatric Nurse Practitioners, Psychologists, Licensed Professional Counselors, Licensed Clinical Social Workers, Licensed Marriage and Family Therapists, Licensed (and certified) Addiction Counselors and pre-licensure counseling candidates. This does not include providers who do not offer commercially reimbursable services (peer support professionals, mental health navigators, etc).

Colorado Insurance Regulation 4-2-24 Concerning Clean Claim Requirements For Health Carriers outlines carrier requirements for processing claims, including required timeframes in which carriers must pay, time periods in which carriers can request additional information from providers, and timeframes in which carriers can  deny claims. Some provisions of this regulation include: 

• What constitutes a “clean claim,”
• the thirty (30)-day window in which carriers may request more claim-specific information;
• the stipulation that a carrier can't deny an unclean claim, 
• the interest a carrier must pay if a clean claim is not paid; 
• and penalties and interest insurance companies must pay if claims are not paid, denied or settled within 90 days (penalty = to 20% of the total amount allowed on all claims not paid, denied or settled within 90) days, etc).

Yes. Colorado Insurance Regulation 4-2-15 requires provisions be included in contracts between insurance companies, individual providers/groups of providers, and authorizing intermediaries to establish that:

• Covered providers/intermediary providers cannot be prohibited from protesting medical decisions or practices made by insurance companies and vice versa.
• Contracts cannot be terminated because:
  • providers/intermediary provider disagrees with decision to deny or limit benefits;
  • provider/intermediary provider discusses any proposed treatment, treatment alternative (covered by the plan or not) make a recommendation of health plan selection based on patient needs; or
  • intermediary providers assist covered people to seek reconsideration from insurance companies.
     

A carrier must conclude the credentialing process for a physician’s application within sixty (60) calendar days after the carrier receives the applicant's completed application. A carrier must provide each applicant written or electronic notice of the outcome of the applicant's credentialing within 10 calendar days after the conclusion of the credentialing process. In addition, carriers must ensure that the process and timeline to review and conclude a behavioral health provider application to join a carrier network must be no more restrictive, challenging, or burdensome than that of a physical health provider.

If a provider or facility is experiencing issues with an insurance company such as reimbursement problems, credentialing or claims issues, the DOI recommends the following:

1. Contact the carrier directly: The provider should attempt to resolve the issue through direct communication with the insurance company.
2. Document: Maintain thorough documentation of all interactions, claims, and relevant details related to the complaint including contact dates and attempts to resolve the issue.
3. Use Formal Carrier-Provider Dispute Process: If the issue is still not resolved, the provider should utilize the process referenced in Colorado Insurance Regulation 4-2-23 (Procedure For Provider-Carrier Dispute Resolution) and file a written dispute with the carrier. Per the regulation, the carrier has specified timeframes and requirements to respond to and settle provider disputes. All carriers are required to have a dispute resolution process in place and provide a form on the provider portal/website in compliance with Colorado Code Regulations, Section 3 CCR 702-4-23-5. 
4. Contact the Division: If the provider has followed these steps and the dispute is still not resolved, or if the carrier did not observe and comply with the rules set forth in the carrier-provider dispute process, then the provider may contact the DOI by emailing dora_bh_provider_issues@state.co.us. 
    

Yes. Commercial health insurance offered in Colorado must comply with the Mental Health Parity and Addiction Equity Act (MHPAEA), as well as other state requirements. There are some general requirements and multiple condition-specific coverage requirements, like for autism spectrum disorder (ASD), preventive services, gender-affirming care, etc.). Health plans must:

• Comply with MHPAEA;
• Provide minimum coverage requirements for Autism Spectrum Disorder (ASD) treatment, including Applied Behavioral Analysis (ABA);
• Follow minimum coverage requirements established in 10-16-104 (18), C.R.S., 2023 Colorado Essential Health Benefit (CO EHB) Plans and HB 19-1269 for the following:
  • Comprehensive Gender Affirming Care for gender dysphoria; 
  • Substance use disorders  - See SUD-specific coverage
  • Mental health services
  • Mental health wellness exam
  • Preventative Health Care Services / behavioral health screenings
  • Any other “A” or “B” rated USPSTF preventive services
     

Yes. Commercial health insurance sold in Colorado must meet the following, non-exhaustive list of coverage requirements:

• Ensure all SUD services align with American Society of Addiction Medicine (ASAM) criteria for placement, medical necessity and utilization management determinations. 
• Comply with Mental Health Parity and Addiction Equity Act (MHPAEA).
• Comply with prescription drug coverage requirements in § 10-16-148(1)(a)(b), C.R.S., Colorado Insurance Regulation 4-2-58 and Colorado Insurance Regulation 4-2-64 that state carriers cannot:
  • Impose prior authorization or step therapy requirements for FDA-approved Medication Assisted Treatment (MAT) for SUD;
  • Place at least one covered FDA-approved prescription medication for the treatment of SUD on the lowest tier; and
  • Apply coverage for pharmacy benefits or prescription drug coverage that is more restrictive than that for a physical illness.
  • Provide the SUD services in the Colorado Essential Health Benefit (CO EHB) Plan.
     

If a patient’s insurance card has “CO-DOI” anywhere on the card, their plan is regulated by the Colorado Division of Insurance (DOI) and the plan must follow State laws and regulations. 
 

Colorado Insurance Regulation 4-2-17  sets forth required guidelines for carriers regarding utilization review timelines, notification requirements, and appeal processes relating to prior authorization, concurrent review, expedited/urgent review requests, retrospective review,  and adverse determinations.