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.
This Unofficial Version Includes Committee
Amendments Not Yet Adopted on Second Reading
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) (I) The commissioner shall
promulgatePage 2, Line 6to implement 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
anyPage 2, Line 11or providers; not have a personal, professional, or financial conflict with
Page 2, Line 12
anyPage 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(II) (A) For claims that allege underpayment for a billed
Page 3, Line 5code where there is a mandated out-of-network reimbursement
Page 3, Line 6rate pursuant to this section, a claimant may only batch claims
Page 3, Line 7if the claimant requests that the division provide the
Page 3, Line 8reimbursement rates as required in subsection (3)(d)(II) of this
Page 3, Line 9section for the disputed claims, determines that they were
Page 3, Line 10underpaid, and files a complaint with the division and the
Page 3, Line 11division does not issue a final decision within sixty days after the date the complaint was filed.
Page 3, Line 12(B) For claims that were paid for by the carrier for a
Page 3, Line 13different billing code than the billing code submitted by the
Page 3, Line 14claimant resulting in a lesser payment to the claimant, the
Page 3, Line 15claimant may proceed directly with the arbitration batching process to dispute the claims.
Page 3, Line 16(d) (I) If the arbitrator's decision made pursuant to subsection
Page 3, Line 17(15)(c) of this section requires additional payment by the carrier above the
Page 3, Line 18amount paid, the carrier shall pay the provider in accordance with section
Page 3, Line 1910-16-106.5. A carrier shall not recalculate a covered person's
Page 3, Line 20cost-sharing amount based on an additional payment required or made as a result of an arbitration decision.
Page 3, Line 21(II) For the purpose of batching claims, the commissioner
Page 3, Line 22shall adopt rules specifying the information each carrier is
Page 3, Line 23required to submit to a provider with the initial payment of a
Page 4, Line 1claim, including but not limited to the information specified in
Page 4, Line 2subsection(15)(d)(III) of this section used by the carrier to
Page 4, Line 3establish network adequacy. Each carrier must provide all
Page 4, Line 4information specified by the commissioner so that a provider may
Page 4, Line 5correctly batch claims in tandem with the delivery of the initial
Page 4, Line 6payment. At the time each initial payment is made, each carrier
Page 4, Line 7must conspicuously disclose in writing to the entity receiving
Page 4, Line 8the initial payment the claims adjustment reason codes and
Page 4, Line 9remittance advice remark codes as described in the federal EDI
Page 4, Line 10835 electronic Health Care Claim Payment/Advice, which serves
Page 4, Line 11as a notice of payments and adjustments sent to providers,
Page 4, Line 12billing entities, and suppliers, and must use the available fields
Page 4, Line 13in the federal EDI 835 electronic Health Care Claim
Page 4, Line 14Payment/Advice to describe if the services provided were in network or out of network.
Page 4, Line 15(III) Each group health benefit plan and each carrier, and
Page 4, Line 16any other issuer of health insurance subject to this section,
Page 4, Line 17shall use exactly one of the following two mutually exclusive
Page 4, Line 18remittance advice remark codes with the initial payment or
Page 4, Line 19notice of denial to clearly identify whether state or federal rules or regulations apply:
Page 4, Line 20(A) An N871 alert: This initial payment was calculated
Page 4, Line 21based on a state-specified law in accordance with the federal "No Surprises Act"; or
Page 4, Line 22(B) An N859 alert: The federal "No Surprises Act" was
Page 4, Line 23applied to the processing of this claim. Payment amounts may be
Page 4, Line 24disputed pursuant to a federal documented appeal, grievance, or dispute resolution process.
Page 5, Line 1SECTION 2. Act subject to petition - effective date. This act
Page 5, Line 2takes effect at 12:01 a.m. on the day following the expiration of the
Page 5, Line 3ninety-day period after final adjournment of the general assembly; except
Page 5, Line 4that, if a referendum petition is filed pursuant to section 1 (3) of article V
Page 5, Line 5of the state constitution against this act or an item, section, or part of this
Page 5, Line 6act within such period, then the act, item, section, or part will not take
Page 5, Line 7effect unless approved by the people at the general election to be held in
Page 5, Line 8November 2026 and, in such case, will take effect on the date of the official declaration of the vote thereon by the governor.