HOUSE BILL 971161
BY REPRESENTATIVES Kreutz, Epps, Gotlieb, Hagedorn, Keller, Lawrence, and Leyba;
also SENATOR Hopper.
CONCERNING THE PROCEDURE FOR DENIAL OF BENEFITS BY
A HEALTH COVERAGE PLAN PURSUANT TO A UTILIZATION REVIEW.
Be it enacted by the General Assembly of the State
of Colorado:
SECTION 1. Part
1 of article 16 of title 10, Colorado Revised Statutes, 1994 Repl.
Vol., as amended, is amended BY THE ADDITION OF A NEW SECTION
to read:
1016113. Procedure for
denial of benefits. (1) A HEALTH
COVERAGE PLAN SHALL NOT MAKE A DETERMINATION THAT IT WILL DENY
A REQUEST FOR REIMBURSEMENT FOR OR COVERAGE OF MEDICAL TREATMENT
OR OTHER BENEFITS FOR A COVERED INDIVIDUAL ON THE GROUNDS THAT
SUCH TREATMENT OR COVERED BENEFIT IS NOT MEDICALLY NECESSARY,
APPROPRIATE, EFFECTIVE, OR EFFICIENT UNLESS SUCH DENIAL IS MADE
PURSUANT TO THIS SECTION.
(2) FOLLOWING A DENIAL BY THE HEALTH COVERAGE
PLAN, SUCH PLAN SHALL NOTIFY THE COVERED PERSON IN WRITING. THE
CONTENT OF SUCH NOTIFICATION AND THE DEADLINES FOR MAKING SUCH
NOTIFICATION SHALL BE MADE PURSUANT TO REGULATIONS PROMULGATED
BY THE COMMISSIONER.
(3) ALL DENIALS OF REQUESTS FOR REIMBURSEMENT
FOR MEDICAL TREATMENT OR OTHER BENEFITS ON THE GROUNDS THAT SUCH
TREATMENT OR COVERED BENEFIT IS NOT MEDICALLY NECESSARY, APPROPRIATE,
EFFECTIVE, OR EFFICIENT SHALL INCLUDE AN EXPLANATION OF THE SPECIFIC
MEDICAL BASIS FOR THE DENIAL AND SHALL ADVISE THE COVERED PERSON
OF THE RIGHT TO APPEAL SUCH DECISION.
(4) ALL WRITTEN DENIALS SHALL BE SIGNED
BY A LICENSED PHYSICIAN FAMILIAR WITH STANDARDS OF CARE IN COLORADO.
(5) A COVERED PERSON'S HEALTH CARE PROVIDER
SHALL HAVE THE ABILITY TO COMMUNICATE WITH THE PHYSICIAN INVOLVED
IN THE INITIAL DECISION TO DENY REIMBURSEMENT FOR OR COVERAGE
OF MEDICAL TREATMENT OR OTHER BENEFITS.
(6) A HEALTH COVERAGE PLAN SHALL DISCLOSE,
UPON REQUEST BY A COVERED PERSON OR A COVERED PERSON'S HEALTH
CARE PROVIDER, ITS STANDARDS FOR DENIAL OF MEDICAL TREATMENTS
OR OTHER BENEFITS ON THE GROUNDS THAT SUCH TREATMENT OR COVERED
BENEFIT IS NOT MEDICALLY NECESSARY, APPROPRIATE, EFFECTIVE, OR
EFFICIENT.
(7) NOTHING IN THIS SECTION SHALL PRECLUDE
OR DENY THE RIGHT OF THE COVERED INDIVIDUAL TO SEEK ANY OTHER
REMEDY OR RELIEF, AND NOTHING IN THIS SECTION SHALL BE A CONDITION
PRECEDENT TO ANY LEGAL PROCEEDING.
SECTION 2. Effective date.
This act shall take effect July 1, 1997.
SECTION 3. Safety
clause. The general assembly hereby finds, determines, and
declares that this act is necessary for the immediate preservation
of the public peace, health, and safety.
____________________________ ____________________________
Charles E. Berry Tom Norton
SPEAKER OF THE HOUSE PRESIDENT OF
OF REPRESENTATIVES THE SENATE
____________________________ ____________________________
Judith M. Rodrigue Joan M. Albi
CHIEF CLERK OF THE HOUSE SECRETARY OF
OF REPRESENTATIVES THE SENATE
APPROVED________________________________________
_________________________________________
Roy Romer
GOVERNOR OF THE STATE
OF COLORADO