House Bill 25-1151 Engrossed

A Bill for an Act

• Page 1, Line 101Concerning the arbitration requirement for batching

• Page 1, Line 102out-of-network health insurance claims.

Bill Summary

(Note: This summary applies to this bill as introduced and does not reflect any amendments that may be subsequently adopted. If this bill passes third reading in the house of introduction, a bill summary that applies to the reengrossed version of this bill will be available at http://leg.colorado.gov.)

The bill makes changes to the arbitration requirements for out-of-network health insurance claims by requiring the arbitration process to include a batching process, by which multiple claims may be considered jointly and under the same arbitration fee as part of one payment determination in alignment with federal law. The commissioner of insurance is required to adopt rules that specify the information each insurance carrier is required to submit to a provider with the initial payment of a claim.

• Page 2, Line 1Be it enacted by the General Assembly of the State of Colorado:

• Page 2, Line 2SECTION 1.  In Colorado Revised Statutes, 10-16-704, amend (15)(b) and (15)(d) as follows:

• Page 2, Line 310-16-704.  Network adequacy - required disclosures - balance

• Page 2, Line 4billing - arbitration - rules - report - legislative declaration -

• Page 2, Line 5definitions. (15) (b)  The commissioner shall promulgate adopt rules to

• Page 2, Line 6implement an arbitration process that establishes a standard arbitration

• Page 2, Line 7form and includes the selection of an arbitrator from a list of qualified

• Page 2, Line 8arbitrators developed pursuant to the rules. Qualified arbitrators must be

• Page 2, Line 9independent; not be affiliated with a carrier, health-care facility, or

• Page 2, Line 10provider or any professional association of carriers, health-care facilities,

• Page 2, Line 11or providers; not have a personal, professional, or financial conflict with

• Page 2, Line 12any the parties to the arbitration; and have experience in health-care

• Page 2, Line 13billing and reimbursement rates. The arbitration process must

• Page 2, Line 14include a batching process for claims made for out-of-network

• Page 2, Line 15emergency services provided to a covered person, by which

• Page 2, Line 16multiple claims may be considered jointly and under the same

• Page 2, Line 17arbitration fee as part of one payment determination, that

• Page 2, Line 18aligns with the batching process in the federal act; the federal

• Page 2, Line 19"Internal Revenue Code of 1986", 26 U.S.C. sec. 9816 (c)(3); the

• Page 2, Line 20federal "Employee Retirement Income Security Act of 1974", 29

• Page 2, Line 21U.S.C. sec. 1001 et seq.; and the federal "Public Health Service

• Page 2, Line 22Act", 42 U.S.C. sec. 201 et seq. The commissioner shall annually

• Page 2, Line 23report on the usage of the batching process as part of the

• Page 2, Line 24division's presentation to its committee of reference at a hearing

• Page 3, Line 1held pursuant to the "State Measurement for Accountable,

• Page 3, Line 2Responsive, and Transparent (SMART) Government Act"

• Page 3, Line 3required pursuant to section 2-7-203. The commissioner shall adopt rules to implement this subsection (15).

• Page 3, Line 4(d) (I)  If the arbitrator's decision made pursuant to subsection

• Page 3, Line 5(15)(c) of this section requires additional payment by the carrier above the

• Page 3, Line 6amount paid, the carrier shall pay the provider in accordance with section

• Page 3, Line 710-16-106.5. A carrier shall not recalculate a covered person's

• Page 3, Line 8cost-sharing amount based on an additional payment required or made as a result of an arbitration decision.

• Page 3, Line 9(II)  For the purpose of batching claims, the commissioner

• Page 3, Line 10shall adopt rules specifying the information each carrier is

• Page 3, Line 11required to submit to a provider with the initial payment of a

• Page 3, Line 12claim, including but not limited to the information specified in

• Page 3, Line 13subsection (1) of this section used by the carrier to establish

• Page 3, Line 14network adequacy. Each carrier must provide all information

• Page 3, Line 15specified by the commissioner so that a provider may correctly

• Page 3, Line 16batch claims in tandem with the delivery of the initial payment.

• Page 3, Line 17At the time each initial payment is made, each carrier must

• Page 3, Line 18conspicuously disclose in writing to the entity receiving the

• Page 3, Line 19initial payment the claims adjustment reason codes and

• Page 3, Line 20remittance advice remark codes as described in the federal EDI

• Page 3, Line 21835 electronic Health Care Claim Payment/Advice, which serves

• Page 3, Line 22as a notice of payments and adjustments sent to providers,

• Page 3, Line 23billing entities, and suppliers, and must use the available fields

• Page 3, Line 24in the federal EDI 835 electronic Health Care Claim

• Page 3, Line 25Payment/Advice to describe if the services provided were in network or out of network.

• Page 4, Line 1(III)  Each group health benefit plan and each carrier, and

• Page 4, Line 2any other issuer of health insurance subject to this section,

• Page 4, Line 3shall use exactly one of the following two mutually exclusive

• Page 4, Line 4remittance advice remark codes with the initial payment or

• Page 4, Line 5notice of denial to clearly identify whether state or federal rules or regulations apply:

• Page 4, Line 6(A)  An N871 alert: This initial payment was calculated

• Page 4, Line 7based on a state-specified law in accordance with the federal "No Surprises Act"; or

• Page 4, Line 8(B)  An N859 alert: The federal "No Surprises Act" was

• Page 4, Line 9applied to the processing of this claim. Payment amounts may be

• Page 4, Line 10disputed pursuant to a federal documented appeal, grievance, or dispute resolution process.

• Page 4, Line 11SECTION 2.  Act subject to petition - effective date. This act

• Page 4, Line 12takes effect at 12:01 a.m. on the day following the expiration of the

• Page 4, Line 13ninety-day period after final adjournment of the general assembly; except

• Page 4, Line 14that, if a referendum petition is filed pursuant to section 1 (3) of article V

• Page 4, Line 15of the state constitution against this act or an item, section, or part of this

• Page 4, Line 16act within such period, then the act, item, section, or part will not take

• Page 4, Line 17effect unless approved by the people at the general election to be held in

• Page 4, Line 18November 2026 and, in such case, will take effect on the date of the official declaration of the vote thereon by the governor.