See bold sections below:
As used in this article, unless the context otherwise requires:
Participation in Products, Plans, or Networks
(1) “Category of coverage” means one of the following types of coverage offered by a person or entity:
(a) Health maintenance organization plans;
(b) Any other commercial plan or contract that is not a health maintenance organization plan;
(d) Medicaid; or
(e) Workers’ compensation.
(2) “CMS” means the federal centers for medicare and medicaid services in the United States department of health and human services.
(3) “CPT code set” means the current procedural terminology code, or its successor code, as developed and copyrighted by the American medical association, or its successor entity, and adopted by the CMS as a HIPAA code set.
(5) “HCPCS” means the health care common procedure coding system developed by the CMS for identifying health care services in a consistent and standardized manner.
(6) “Health care contract” or “contract” means a contract entered into or renewed between a person or entity and a health care provider for the delivery of health care services to others.
(7) “Health care provider” means a person licensed or certified in this state to practice medicine, pharmacy, chiropractic, nursing, physical therapy, podiatry, dentistry, optometry, occupational therapy, or other healing arts. “Health care provider” also means an ambulatory surgical center, a licensed pharmacy or provider of pharmacy services, and a professional corporation or other corporate entity consisting of licensed health care providers as permitted by the laws of this state.
(8) “HIPAA code set” means any set of codes used to encode elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes, that have been adopted by the secretary of the United States department of health and human services pursuant to the federal “Health Insurance Portability and Accountability Act of 1996”, as amended. “HIPAA code set” includes the codes and the descriptors of the codes.
Participation in Products, Plans, or Networks; Amendment
(9)(a) “Material change” means a change to a contract that decreases the health care provider’s payment or compensation, changes the administrative procedures in a way that may reasonably be expected to significantly increase the provider’s administrative expense, replaces the maximum allowable cost list used with a new and different maximum allowable cost list by a person or entity for reimbursement of generic prescription drug claims, or adds a new category of coverage.
(b) “Material change” does not include:
(I) A decrease in payment or compensation resulting solely from a change in a published fee schedule upon which the payment or compensation is based and the date of applicability is clearly identified in the contract;
(II) A decrease in payment or compensation resulting from a change in the fee schedule specified in a contract for pharmacy services such as a change in a fee schedule based on average wholesale price or maximum allowable cost;
(III) A decrease in payment or compensation that was anticipated under the terms of the contract, if the amount and date of applicability of the decrease is clearly identified in the contract;
(IV) An administrative change that may significantly increase the provider’s administrative expense, the specific applicability of which is clearly identified in the contract;
(V) Changes to an existing prior authorization, precertification, notification, or referral program that do not substantially increase the provider’s administrative expense; or
(VI) Changes to an edit program or to specific edits; however, the person or entity shall provide notice of the changes to the health care provider in accordance with paragraph (c) of this subsection (9), and the notice shall include information sufficient for the health care provider to determine the effect of the change.
(c) If a change to the contract is administrative only and is not a material change, the change shall be effective upon at least fifteen days’ notice to the health care provider. All other notices shall be provided pursuant to the contract.
(10) “National correct coding initiative” or “NCCI” means the system developed by the CMS to promote consistency in national correct coding methodologies and to control improper coding leading to inappropriate payment in medicare part B claims for professional services.
(11) “National initiative” means a collaborative effort led by or occurring under the direction of the secretary of the United States department of health and human services, which includes a diverse group of stakeholders, to create a level of understanding of the impact of coding edits on the industry and a uniform, standardized set of claim edits that meets the needs of the stakeholders in the industry.
(12) “Person or entity” means a person or entity that has a primary business purpose of contracting with health care providers for the delivery of health care services.
(13) “Pharmacy benefit manager” means an entity doing business in this state that contracts to administer or manage prescription drug benefits on behalf of any carrier that provides prescription drug benefits to residents of this state. “Pharmacy benefit manager” does not include the department of health care policy and financing created in section 25.5-1-104, C.R.S.