State Law

Colorado Rev. Statutes-Title 12-Article 30-Part 1. Miscellaneous Provisions Applicable to Health Care Professions and Occupations

08/23/2022 Colorado Section 12-30-113

Out-of-network health care providers – out-of-network services – billing – payment

Claims Filing Deadlines, OON-Payment Issues

Note:  This entire section falls under the category entitled “OON-Payment Issues.”  The bold language below identifies the portion of this statute that falls under the category “Claims Filing Deadlines.”

(1) If an out-of-network health care provider provides emergency services or covered nonemergency services to a covered person at an in-network facility, the out-of-network provider shall:

(a) Submit a claim for the entire cost of the services to the covered person’s carrier; and

(b) Not bill or collect payment from a covered person for any outstanding balance for
covered services not paid by the carrier, except for the applicable in-network coinsurance,
deductible, or copayment amount required to be paid by the covered person.

(2) (a) If an out-of-network health care provider provides covered nonemergency
services at an in-network facility or emergency services at an out-of-network or in-network facility and the health care provider receives payment from the covered person for services for which the covered person is not responsible pursuant to section 10-16-704 (3)(b) or (5.5), the health care provider shall reimburse the covered person within sixty calendar days after the date that the overpayment was reported to the provider.

(b) An out-of-network health care provider that fails to reimburse a covered person as
required by subsection (2)(a) of this section for an overpayment shall pay interest on the
overpayment at the rate of ten percent per annum beginning on the date the provider received the notice of the overpayment. The covered person is not required to request the accrued interest from the out-of-network health care provider in order to receive interest with the reimbursement amount.

(3) An out-of-network health care provider shall provide a covered person a written
estimate of the amount for which the covered person may be responsible for covered
nonemergency services within three business days after a request from the covered person.

Claims Filing Deadlines

(4) (a) An out-of-network health care provider must send a claim for a covered service to the carrier within one hundred eighty days after the receipt of insurance information in order to receive reimbursement as specified in this subsection (4)(a). The reimbursement rate is the
greater of:

(I) One hundred ten percent of the carrier’s median in-network rate of reimbursement
for that service provided in the same geographic area; or

(II) The sixtieth percentile of the in-network rate of reimbursement for the same service in the same geographic area for the prior year based on claims data from the all-payer health claims database described in section 25.5-1-204.

(b) If the out-of-network health care provider submits a claim for covered services after
the one-hundred-eighty-day period specified in subsection (4)(a) of this section, the carrier shall reimburse the health care provider one hundred twenty-five percent of the medicare
reimbursement rate for the same services in the same geographic area.

(c) The health care provider shall not bill a covered person any outstanding balance for a
covered service not paid for by the carrier, except for any coinsurance, deductible, or copayment amount required to be paid by the covered person.

(5) A health care provider may initiate arbitration pursuant to section 10-16-704 (15) if
the health care provider believes the payment made pursuant to subsection (4) of this section is not sufficient.

See https://law.justia.com/codes/colorado/2020/title-12/article-30/section-12-30-113/