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Second Regular Session
Sixty-first General Assembly
LLS NO. 980499.01 BWM
SENATE BILL 98095
STATE OF COLORADO
BY SENATOR Hernandez
BUSINESS AFFAIRS & LABOR
A BILL FOR AN ACT
CONCERNING THE DENIAL OF PERSONAL INJURY PROTECTION
BENEFITS (PIP) UNDER AUTOMOBILE NOFAULT INSURANCE POLICIES,
AND, IN CONNECTION THEREWITH, ESTABLISHING STANDARDS FOR THE CONDUCT
OF PIP EXAMINATIONS UNDER THE PIP EXAMINATION PROGRAM AND REQUIRING
THE REIMBURSEMENT OF LICENSED PROVIDERS FOR SERVICES DETERMINED
TO BE REASONABLE AND NECESSARY.
(Note: This summary applies to this bill as introduced
and does not necessarily reflect any amendments that may be subsequently
Adds a definition of "PIP examination"
to the provisions of law dealing with PIP reviews. Specifies
that an insurer shall not deny benefits to an insured or injured
person entitled to PIP benefits under a disputed PIP claim until
the insurer has obtained a PIP examination. Specifies the requirements
for PIP examinations. Specifies penalties under the insurance
laws for failing to follow these procedures. Requires reimbursement
under auto nofault policies to certain licensed providers.
Permits the use of fee schedules for such reimbursements. Prohibits
discrimination between types of providers for the same services
in such fee schedules. If a PIP examination is conducted at the
request of an insured or injured person and a PIP review panel
member determines that any portion of the treatment rendered to
such person is reasonable and necessary, requires the insurer
to reimburse the insured for the costs of the PIP examination.
Be it enacted by the General Assembly of the State of Colorado:
SECTION 1. 104703, Colorado Revised Statutes, is amended BY THE ADDITION OF A NEW SUBSECTION to read:
104703. Definitions. As used in this part 7, unless the context otherwise requires:
(13) "PIP EXAMINATION" MEANS ANY REVIEW OR EVALUATION OF A HEALTH CARE PRACTITIONER'S TREATMENT SOUGHT BY A PARTY TO A DISPUTED PIP CLAIM FROM A LICENSED HEALTH CARE PRACTITIONER NOT EMPLOYED OR UNDER THE DIRECTION OR CONTROL OF A PARTY TO THE CLAIM.
SECTION 2. 104706, Colorado Revised Statutes, is amended BY THE ADDITION OF THE FOLLOWING NEW SUBSECTIONS to read:
104706. Required coverages complying policies PIP examination program. (7) (a) AN INSURER SHALL NOT DENY BENEFITS TO AN INSURED OR INJURED PERSON ENTITLED TO BENEFITS UNDER A DISPUTED PIP CLAIM UNTIL THE INSURER HAS OBTAINED A PIP EXAMINATION.
(b) A PIP EXAMINATION SHALL BE BY A PIP REVIEW PANEL MEMBER, UNLESS OTHERWISE AGREED TO AT THE TIME OF THE DISPUTED PIP CLAIM BY THE PARTIES.
(8) (a) THE USE OF A PRIVATE UTILIZATION REVIEW OR PRIVATE PAPER REVIEW TO DENY A PIP CLAIM WITHOUT A PIP EXAMINATION SHALL SUBJECT THE INSURER TO THE PENALTIES UNDER SECTIONS 104115 (2), 1031104, AND 1031108 OR ANY COMMON LAW REMEDY OF THE INSURED.
(b) THE USE OF A NONHEALTH CARE PRACTITIONER REVIEW TO DENY A PIP CLAIM WITHOUT A PIP EXAMINATION SHALL SUBJECT THE INSURER TO THE PENALTIES UNDER SECTIONS 104115 (2), 1031104, AND 1031108 OR ANY COMMON LAW REMEDY OF THE INSURED.
(9) (a) NOTWITHSTANDING ANY PROVISIONS OF ANY POLICY UNDER THIS PART 7 ISSUED BY AN INSURER, WHENEVER ANY SUCH POLICY OR PLAN PROVIDES FOR REIMBURSEMENT FOR ANY SERVICE THAT MAY BE LAWFULLY PERFORMED BY A PERSON LICENSED IN THIS STATE FOR THE PRACTICE OF OSTEOPATHY, MEDICINE, DENTISTRY, DENTAL HYGIENE, OPTOMETRY, PSYCHOLOGY, CHIROPRACTIC, OR PODIATRY, REIMBURSEMENT UNDER SUCH POLICY OR PLAN SHALL NOT BE DENIED WHEN SUCH SERVICE IS RENDERED BY A PERSON SO LICENSED. NOTHING IN THIS PARAGRAPH (a) SHALL PRECLUDE AN INSURER FROM SETTING DIFFERENT FEE SCHEDULES IN AN INSURANCE POLICY FOR DIFFERENT SERVICES PERFORMED BY DIFFERENT PROFESSIONS, BUT THE SAME FEE SCHEDULE SHALL BE USED FOR THOSE PORTIONS OF HEALTH SERVICE THAT ARE SUBSTANTIALLY IDENTICAL ALTHOUGH PERFORMED BY DIFFERENT PROFESSIONS.
(b) THE LICENSED PERSONS WHO MAY NOT BE DENIED REIMBURSEMENT PURSUANT TO PARAGRAPH (a) OF THIS SUBSECTION (9) SHALL INCLUDE REGISTERED PROFESSIONAL NURSES AND LICENSED CLINICAL SOCIAL WORKERS. HOWEVER, SUCH INCLUSION SHALL NOT BE INTERPRETED AS ENLARGING THE SCOPE OF PROFESSIONAL NURSING OR LICENSED CLINICAL SOCIAL WORKER PRACTICE. FOR THE PURPOSES OF THIS SUBSECTION (9), "LICENSED CLINICAL SOCIAL WORKER" SHALL HAVE THE SAME MEANING SET FORTH IN SECTION 1016104 (5) (b) (III).
(c) REIMBURSEMENT FOR ANY SERVICE SHALL NOT BE DETERMINED BY TYPE OF PROVIDER, AND IT SHALL BE UNLAWFUL TO DISCRIMINATE BETWEEN TYPES OF PROVIDERS OR TO USE A DIFFERENT FEE SCHEDULE FOR TYPES OF PROVIDERS FOR THE SAME SERVICE.
(10) (a) IF AN INSURED OR INJURED PERSON ENTITLED TO BENEFITS HAS BEEN DENIED A PIP CLAIM AND REQUESTS A PIP EXAMINATION BY A PIP REVIEW PANEL MEMBER AND THE REPORT OF THE PIP EXAMINER DETERMINES THAT ANY PORTION OF THE TREATMENT RENDERED TO THE INSURED OR INJURED PERSON ENTITLED TO BENEFITS IS REASONABLE AND NECESSARY, AND IF SUCH CLAIMED INJURY OR CONDITION ARISES OUT OF THE USE OF A MOTOR VEHICLE, THE INSURER SHALL REIMBURSE THE INSURED FOR THE COSTS OF THE EXAMINATION.
(b) THE RIGHT TO REIMBURSEMENT SET FORTH IN PARAGRAPH (a) OF THIS SUBSECTION (10) SHALL BE SET FORTH IN THE FACT SHEET REQUIRED UNDER PARAGRAPH (b) OF SUBSECTION (4) OF THIS SECTION.
SECTION 3. Effective date applicability. This act shall take effect upon passage and shall apply to claims for automobile nofault insurance personal injury protection (PIP) on or after said date.
SECTION 4. 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.