State Law

Code of Colorado Regs-3 CCR 702-4 Series 4-2

07/30/2023 Colorado Section 4-2-79

Concerning the requirements for provider data requests and carrier responses confirming out-of-network payment methodology utilization

OON-Payment Issues

Section 1. Authority

This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of §§
10-1-109(1), 10-16-109, and 10-16-704(13), C.R.S.

Section 2. Scope and Purpose

The purpose of this regulation is to establish the requirements for provider and health care facility
submitted requests for out-of-network payment methodology data from carriers pursuant to § 10-16-
704(13), C.R.S., as well as the fields that must be supplied in any response provided by a carrier
pursuant to that same statute.

Section 3. Applicability

This regulation applies to all provider and health care facility requests and carrier responses to data
requests pursuant to § 10-16-704(13), C.R.S.

Section 4. Definitions

A. “Carrier” shall have the same meaning as found at § 10-16-102(8), C.R.S.

B. “Commissioner” means, for the purposes of this regulation, the Commissioner of Insurance or his
or her designee.

C. “Out-of-network provider” means, for the purposes of this regulation, a provider in this state that
has not entered into a contract with a carrier or with its contractor or subcontractor to provide
health care services to covered persons.

D. “Provider” shall have the same meaning as found at § 10-16-102(56), C.R.S.

Section 5. Requirements for Data Requests and Carrier Responses

A. An out-of-network provider or health care facility that has received payment pursuant to § 10-16-
704(13), C.R.S., and is submitting a request to the Commissioner seeking data to evaluate the
carrier’s compliance in paying the highest rate required in § 10-16-704(3)(d) or (5.5)(b), C.R.S.
must utilize the “Out-of-Network Data Request and Response Form found in Appendix A” of this

B. A separate spreadsheet containing multiple claims must be submitted for each distinct facility or
provider requesting confirmation that the appropriate payment methodology was used pursuant to
§ 10-16-704(3)(d) or (5.5)(b), C.R.S.

C. All provider fields in the “Out-of-Network Data Request and Response Form” must be populated
by the requesting provider or health care facility prior to the form being sent to the Division. An
incomplete form will not be sent to the applicable carrier until it has been completely populated by
the requesting provider.

D. Upon receipt of an “Out-of-Network Data Request and Response Form” from the Division, a
carrier shall populate the carrier fields and return the completed template to the Division no later
than thirty (30) calendar days after receipt. Additional time to respond may be granted by the
Division when the “Out-of-Network Data Request and Response Form” contains more than one
hundred (100) claims. The fields populated by the carrier in response to a request from the
Division must identify which out-of-network payment methodologies and amounts were
considered in determining payment, clearly state which methodology and payment was selected,
and include a description of how the carrier has determined its median in-network rate.

E. Upon request by the Division, the carrier shall provide a separate document containing the
methodology for determining the carrier’s median in-network rate or reimbursement for each
service in the same geographic area, to accompany a specified completed “Out-of-Network Data
Request and Response Form.”

Section 6. Severability

If any provision of this regulation or the application of it to any person or circumstances is for any reason
held to be invalid, the remainder of this regulation shall not be affected.

Section 7. Enforcement

Noncompliance with this regulation may result in the imposition of any of the sanctions made available in
the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition
of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license,
subject to the requirements of due process.

Section 8. Effective Date

This regulation shall become effective January 15, 2022.

Section 9. History

New regulation effective January 15, 2022.