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 - legislative declaration - definitions.
Page 2, Line 5(15) (b) The commissioner shall
promulgatePage 2, Line 6an arbitration process that establishes a standard arbitration form and
Page 2, Line 7includes the selection of an arbitrator from a list of qualified arbitrators
Page 2, Line 8developed 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, by which multiple claims may be
Page 2, Line 15considered jointly and under the same arbitration fee as part of
Page 2, Line 16one payment determination, that aligns with the batching
Page 2, Line 17process in the federal act; the federal "Internal Revenue Code
Page 2, Line 18of 1986", 26 U.S.C. sec. 9816 (c)(3); the federal "Employee
Page 2, Line 19Retirement Income Security Act of 1974", 29 U.S.C. sec. 1001 et
Page 2, Line 20seq.; and the federal "Public Health Service Act", 42 U.S.C. sec.
Page 2, Line 21201 et seq. The commissioner shall adopt rules to implement this subsection (15).
Page 2, Line 22(d) (I) If the arbitrator's decision made pursuant to subsection
Page 2, Line 23(15)(c) of this section requires additional payment by the carrier above the
Page 3, Line 1amount paid, the carrier shall pay the provider in accordance with section
Page 3, Line 210-16-106.5. A carrier shall not recalculate a covered person's
Page 3, Line 3cost-sharing amount based on an additional payment required or made as a result of an arbitration decision.
Page 3, Line 4(II) For the purpose of batching claims, the commissioner
Page 3, Line 5shall adopt rules specifying the information each carrier is
Page 3, Line 6required to submit to a provider with the initial payment of a
Page 3, Line 7claim, including but not limited to the information specified in
Page 3, Line 8subsection (1) of this section used by the carrier to establish
Page 3, Line 9network adequacy. Each carrier must provide all information
Page 3, Line 10specified by the commissioner so that a provider may correctly
Page 3, Line 11batch claims in tandem with the delivery of the initial payment.
Page 3, Line 12At the time each initial payment is made, each carrier must
Page 3, Line 13conspicuously disclose in writing to the entity receiving the
Page 3, Line 14initial payment the claims adjustment reason codes and
Page 3, Line 15remittance advice remark codes as described in the federal EDI
Page 3, Line 16835 electronic Health Care Claim Payment/Advice, which serves
Page 3, Line 17as a notice of payments and adjustments sent to providers,
Page 3, Line 18billing entities, and suppliers, and must use the available fields
Page 3, Line 19in the federal EDI 835 electronic Health Care Claim
Page 3, Line 20Payment/Advice to describe if the services provided were in network or out of network.
Page 3, Line 21(III) Each group health benefit plan and each carrier, and
Page 3, Line 22any other issuer of health insurance subject to this section,
Page 3, Line 23shall use exactly one of the following two mutually exclusive
Page 3, Line 24remittance advice remark codes with the initial payment or
Page 3, Line 25notice of denial to clearly identify whether state or federal rules or regulations apply:
Page 4, Line 1(A) An N871 alert: This initial payment was calculated
Page 4, Line 2based on a state-specified law in accordance with the federal "No Surprises Act"; or
Page 4, Line 3(B) An N859 alert: The federal "No Surprises Act" was
Page 4, Line 4applied to the processing of this claim. Payment amounts may be
Page 4, Line 5disputed pursuant to a federal documented appeal, grievance, or dispute resolution process.
Page 4, Line 6SECTION 2. Act subject to petition - effective date. This act
Page 4, Line 7takes effect at 12:01 a.m. on the day following the expiration of the
Page 4, Line 8ninety-day period after final adjournment of the general assembly; except
Page 4, Line 9that, if a referendum petition is filed pursuant to section 1 (3) of article V
Page 4, Line 10of the state constitution against this act or an item, section, or part of this
Page 4, Line 11act within such period, then the act, item, section, or part will not take
Page 4, Line 12effect unless approved by the people at the general election to be held in
Page 4, Line 13November 2026 and, in such case, will take effect on the date of the official declaration of the vote thereon by the governor.