Second Regular Session
Sixty-first General Assembly
LLS NO. 980810.01D EBD
HOUSE BILL 981377
STATE OF COLORADO
BY REPRESENTATIVE Morrison
HEWI
A BILL FOR AN ACT
CONCERNING INDEPENDENT REVIEW FOR THE DENIAL OF BENEFITS
UNDER A HEALTH INSURANCE PLAN.
Bill Summary
(Note: This summary applies to this bill as introduced
and does not necessarily reflect any amendments that may be subsequently
adopted.)
Declares that covered individuals should have access to independent review of health care coverage decisions. Defines "covered individual requesting independent review" as someone who was denied coverage who has complied with internal appeal decisions. Defines "expert reviewer" as a licensed health care professional who is an expert in the covered person's illness. Defines "expedited review", and sets forth specific deadlines for accomplishing an expedited review. Defines "independent review entity" as an entity that contracts with a plan to conduct independent reviews of determinations by that health benefit plan. Requires the disclosure of the ownership and management of the independent review entity. Forbids conflicts of interest between the reviewer and the plan, health care providers, and the covered person.
Requires the plan to provide information to the commissioner regarding the independent review process and a certification that the entity meets the requirements of this section.
Requires plans to provide independent review processes and to notify the covered person of the availability of the process. Requires the plan to notify persons who have been denied coverage of the availability of independent review and specifies the contents of that notification. Limits the availability of independent review to within 60 days of the initial coverage decision. Specifies that the covered person is responsible for the first $100 of the cost of an independent review.
Sets forth deadlines for the provision of information to the reviewer and for the reviewer to make a determination. Requires the determination to be in writing. Sets forth the required elements of the determination. Makes the reviewer's determination binding on the plan. Specifies that the plan is not required to cover services not included in the contract. Absolves the entity and reviewer from liability for determinations, except for those made in bad faith or involving gross negligence.
Specifies that a violation of this section is an
unfair method of competition and an unfair or deceptive act or
practice in the business of insurance.
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, is amended BY THE ADDITION OF A NEW SECTION to read:
1016113.5. Independent external review of benefit denials legislative declaration definitions. (1) THE GENERAL ASSEMBLY HEREBY FINDS, DETERMINES, AND DECLARES THAT IN THE INTEREST OF IMPROVING ACCOUNTABILITY FOR HEALTH CARE COVERAGE DECISIONS, COVERED INDIVIDUALS SHOULD HAVE THE OPTION OF AN INDEPENDENT REVIEW BY QUALIFIED EXPERTS WHEN THEY HAVE BEEN DENIED A REQUEST FOR COVERAGE PURSUANT TO THEIR HEALTH PLAN'S PROCEDURES FOR DENIAL OF BENEFITS REQUIRED BY SECTION 1016113.
(2) AS USED IN THIS SECTION, UNLESS THE CONTEXT OTHERWISE REQUIRES:
(a) "COVERED INDIVIDUAL REQUESTING AN INDEPENDENT REVIEW" MEANS:
(I) (A) A COVERED PERSON WHO HAS FOLLOWED ALL OF THE PROCEDURES AND LEVELS OF APPEALS FOR A DENIAL OF BENEFITS REQUESTED TO BE PROVIDED BY A PLAN PURSUANT TO SECTION 1016113 AND RULES RELATED THERETO AND WHO HAS REQUESTED AN INDEPENDENT REVIEW PURSUANT TO THIS SECTION; OR
(B) A COVERED PERSON WHO HAS PURSUED AN EXPEDITED INTERNAL REVIEW OF A DENIAL OF A BENEFIT PURSUANT TO REGULATIONS PROMULGATED BY THE COMMISSIONER AND FOR WHOM, IN THE OPINION OF THE COVERED PERSON'S PHYSICIAN, THE DEADLINES OF AN INTERNAL SECOND LEVEL INTERNAL PLAN REVIEW WOULD SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE COVERED PERSON OR WOULD JEOPARDIZE THE COVERED PERSON'S ABILITY TO REGAIN MAXIMUM FUNCTION.
(II) THE TERM "COVERED INDIVIDUAL REQUESTING AN INDEPENDENT REVIEW" SHALL ALSO INCLUDE THE DESIGNATED REPRESENTATIVE OF A COVERED INDIVIDUAL REQUESTING AN INDEPENDENT REVIEW.
(b) "EXPEDITED REVIEW" MEANS A REVIEW FOLLOWING COMPLETION OF PROCEDURES FOR INTERNAL REVIEW OF AN ADVERSE DETERMINATION INVOLVING A SITUATION WHERE THE TIME FRAME OF THE STANDARD REVIEW PROCEDURES WOULD SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE COVERED PERSON OR WOULD JEOPARDIZE THE COVERED PERSON'S ABILITY TO REGAIN MAXIMUM FUNCTION.
(c) "EXPERT REVIEWER" MEANS A PHYSICIAN OR OTHER APPROPRIATE HEALTH CARE PROVIDER ASSIGNED BY AN INDEPENDENT REVIEW ENTITY TO CONDUCT AN INDEPENDENT REVIEW WHO:
(I) IS AN EXPERT IN THE TREATMENT OF THE MEDICAL CONDITION OF THE COVERED INDIVIDUAL REQUESTING AN INDEPENDENT REVIEW AND KNOWLEDGEABLE ABOUT THE RECOMMENDED TREATMENT OR SERVICE THAT IS THE SUBJECT OF THE REVIEW THROUGH THE EXPERT'S ACTUAL CLINICAL EXPERIENCE;
(II) HOLDS A LICENSE ISSUED BY A STATE, AND FOR PHYSICIANS, A CURRENT CERTIFICATION BY A RECOGNIZED AMERICAN MEDICAL SPECIALTY BOARD IN THE AREA APPROPRIATE TO THE SUBJECT OF REVIEW; AND
(III) HAS NO HISTORY OF DISCIPLINARY ACTION OR SANCTION, INCLUDING LOSS OF STAFF PRIVILEGES OR PARTICIPATION RESTRICTIONS, TAKEN OR PENDING BY ANY HOSPITAL, GOVERNMENT, OR REGULATORY BODY.
(d) "INDEPENDENT REVIEW ENTITY" MEANS AN ENTITY THAT MEETS THE REQUIREMENTS OF THIS SECTION AND CONTRACTS WITH A HEALTH COVERAGE PLAN TO CONDUCT AN INDEPENDENT REVIEW OF A DETERMINATION BY THE PLAN TO DENY A REQUEST FOR REIMBURSEMENT FOR OR COVERAGE OF MEDICAL TREATMENT OR OTHER MEDICAL BENEFIT FOR A COVERED INDIVIDUAL ON THE GROUNDS THAT SUCH TREATMENT OR COVERED BENEFIT IS NOT MEDICALLY NECESSARY, MEDICALLY APPROPRIATE, MEDICALLY EFFECTIVE, OR MEDICALLY EFFICIENT.
(3) TO QUALIFY AS AN INDEPENDENT REVIEW ENTITY, SUCH ENTITY SHALL MEET THE FOLLOWING REQUIREMENTS:
(a) THE INDEPENDENT REVIEW ENTITY HAS A QUALITY ASSURANCE PROCEDURE THAT ENSURES THE TIMELINESS AND QUALITY OF THE REVIEWS CONDUCTED PURSUANT TO THIS SECTION, THE QUALIFICATIONS AND INDEPENDENCE OF THE REVIEW EXPERTS, AND THE CONFIDENTIALITY OF MEDICAL RECORDS AND REVIEW MATERIALS.
(b) THE INDEPENDENT REVIEW ENTITY MAINTAINS PATIENT CONFIDENTIALITY PURSUANT TO COLORADO AND FEDERAL LAW.
(c) THE INDEPENDENT REVIEW ENTITY PUBLISHES A SUMMARY OF RESULTS OF REVIEWS CONDUCTED OVER THE LAST THREE YEARS.
(4) A HEALTH COVERAGE PLAN SHALL ONLY CONTRACT WITH INDEPENDENT REVIEW ENTITIES THAT IT HAS DETERMINED:
(a) EITHER MEET THE REQUIREMENTS SET FORTH IN SUBSECTION (3) OF THIS SECTION OR MEET SUBSTANTIALLY SIMILAR REQUIREMENTS;
(b) ARE NOT A SUBSIDIARY OF, OR IN ANY WAY OWNED OR CONTROLLED BY, A CARRIER, TRADE ASSOCIATION OF CARRIERS, OR A PROFESSIONAL ASSOCIATION OF HEALTH CARE PROVIDERS;
(c) MAINTAIN DOCUMENTATION AVAILABLE FOR REVIEW BY THE DIVISION OF INSURANCE UPON REQUEST THAT SHALL INCLUDE THE FOLLOWING:
(I) THE NAMES OF ALL STOCKHOLDERS AND OWNERS OF MORE THAN FIVE PERCENT OF SUCH STOCK OR OPTIONS;
(II) THE NAMES OF ALL HOLDERS OF BONDS OR NOTES IN AMOUNTS IN EXCESS OF ONE HUNDRED THOUSAND DOLLARS;
(III) THE NAMES OF ALL CORPORATIONS AND ORGANIZATIONS THAT THE INDEPENDENT REVIEW ENTITY CONTROLS OR IS AFFILIATED WITH, AND THE NATURE AND EXTENT OF ANY OWNERSHIP OR CONTROL, INCLUDING THE AFFILIATED ORGANIZATION'S BUSINESS ACTIVITIES;
(IV) THE NAMES OF ALL DIRECTORS, OFFICERS, AND EXECUTIVES OF THE INDEPENDENT ENTITY AND A STATEMENT REGARDING ANY RELATIONSHIP THE DIRECTORS, OFFICERS, OR EXECUTIVES MAY HAVE WITH ANY HEALTH BENEFIT PLAN OR CARRIER.
(d) (I) DO NOT HAVE ANY MATERIAL PROFESSIONAL, FAMILY, OR FINANCIAL CONFLICT OF INTEREST WITH:
(A) THE HEALTH BENEFIT PLAN OR ANY OFFICER, DIRECTOR, OR EXECUTIVE OF THE HEALTH BENEFIT PLAN;
(B) THE COVERED PERSON'S PHYSICIAN OR THE COVERED PERSON'S PHYSICIAN'S MEDICAL GROUP;
(C) THE INSTITUTION AT WHICH THE TREATMENT OR SERVICE WOULD BE PROVIDED;
(D) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, DEVICE, PROCEDURE, TREATMENT, OR SERVICE PROPOSED FOR THE COVERED PERSON WHOSE TREATMENT IS UNDER REVIEW; OR
(E) THE COVERED PERSON.
(II) NOTHING IN SUBPARAGRAPH (I) OF THIS PARAGRAPH (d) SHALL BE CONSTRUED TO INCLUDE:
(A) A CONTRACT UNDER WHICH AN ACADEMIC MEDICAL CENTER, OR OTHER SIMILAR MEDICAL RESEARCH CENTER, PROVIDES HEALTH SERVICES TO PERSONS INSURED BY THE HEALTH BENEFIT PLAN, EXCEPT AS SPECIFIED IN SUBSUBPARAGRAPH (C) OF SUBPARAGRAPH (I) OF THIS PARAGRAPH (d);
(B) AFFILIATIONS THAT ARE LIMITED TO STAFF PRIVILEGES AT A HEALTH CARE INSTITUTION; OR
(C) AN EXPERT REVIEWER'S PARTICIPATION AS A CONTRACTING HEALTH BENEFIT PLAN PROVIDER WHERE THE EXPERT IS AFFILIATED WITH AN ACADEMIC MEDICAL CENTER, OR SIMILAR MEDICAL RESEARCH CENTER, THAT IS ACTING AS AN INDEPENDENT REVIEW ENTITY PURSUANT TO THIS SECTION.
(5) A HEALTH COVERAGE PLAN SHALL INCLUDE WITH ITS ANNUAL FINANCIAL STATEMENT FILING A CERTIFICATION SIGNED BY AN OFFICER OF THE HEALTH CARE PLAN THAT STATES THAT THE PLAN HAS:
(a) REVIEWED THE INDEPENDENT REVIEW ENTITY WITH WHICH IT HAS CONTRACTED, AND HAS DETERMINED THAT IT MEETS THE REQUIREMENTS OF SUBSECTION (3) OF THIS SECTION.
(b) CONTRACTS ONLY WITH THE INDEPENDENT REVIEW ENTITIES NAMED IN THE CERTIFICATION AND SHALL INCLUDE THE INDEPENDENT REVIEW ENTITIES' CONTACT PERSON'S NAME, ADDRESS, AND TELEPHONE NUMBER.
(c) RECEIVED INFORMATION FROM THE INDEPENDENT REVIEW ENTITY DEMONSTRATING THAT THE INDEPENDENT REVIEW ENTITY COMPLIES WITH THE REQUIREMENTS OF THIS SECTION AND THAT THE HEALTH BENEFIT PLAN MAINTAINS SUCH DOCUMENTATION.
(6) UPON THE REQUEST OF ANY COVERED PERSON THE HEALTH COVERAGE PLAN SHALL PROVIDE A COPY OF THE INDEPENDENT REVIEW INFORMATION MAINTAINED BY THE HEALTH COVERAGE PLAN PURSUANT TO SUBSECTION (5) OF THIS SECTION. THE HEALTH COVERAGE PLAN MAY IMPOSE A REASONABLE CHARGE TO ANY PERSON FOR SUCH COPIES. THE PLAN SHALL ALSO MAKE COPIES OF SUCH DOCUMENTS AVAILABLE FOR REVIEW AT NO COST DURING REGULAR BUSINESS HOURS.
(7) A HEALTH COVERAGE PLAN SHALL FURNISH INFORMATION ON QUALIFIED INDEPENDENT REVIEW ENTITIES TO COVERED PERSONS REQUESTING AN INDEPENDENT REVIEW. THE PLAN MAY MAKE A RECOMMENDATION ABOUT WHICH ENTITY SHOULD CONDUCT THE REVIEW; EXCEPT THAT THE COVERED PERSON SHALL HAVE THE RIGHT OF SELECTION FROM THOSE ENTITIES ABOUT WHICH THE INFORMATION WAS PROVIDED.
(8) HEALTH COVERAGE PLANS SHALL MAKE AVAILABLE AN INDEPENDENT REVIEW PROCESS THAT MEETS THE REQUIREMENTS OF THIS SECTION.
(9) ALL HEALTH COVERAGE PLAN MATERIALS DEALING WITH THE PLAN'S GRIEVANCE PROCEDURES SHALL ADVISE COVERED PERSONS IN WRITING OF THE AVAILABILITY OF AN INDEPENDENT REVIEW PROCESS, THE CIRCUMSTANCES UNDER WHICH A COVERED PERSON MAY USE THE INDEPENDENT REVIEW PROCESS, THE PROCEDURES FOR REQUESTING AN INDEPENDENT REVIEW, AND THE DEADLINES ASSOCIATED WITH AN INDEPENDENT REVIEW.
(10) A COVERED PERSON REQUESTING AN INDEPENDENT REVIEW SHALL MAKE SUCH REQUEST WITHIN SIXTY DAYS AFTER RECEIVING NOTIFICATION OF THE DENIAL OF COVERAGE FOR SUCH TREATMENT OR SERVICE. SUCH NOTIFICATION OF THE DENIAL OF COVERAGE SHALL INCLUDE A NOTIFICATION OF THE PERSON'S RIGHT TO AN INDEPENDENT REVIEW. A COVERED PERSON SHALL NOTIFY THE PLAN IF THE COVERED PERSON REQUESTS AN EXPEDITED REVIEW.
(11) WITHIN FIVE BUSINESS DAYS AFTER A WRITTEN REQUEST FOR AN INDEPENDENT REVIEW, A HEALTH COVERAGE PLAN SHALL NOTIFY THE COVERED PERSON IN WRITING. SUCH NOTIFICATION SHALL INCLUDE:
(a) DESCRIPTIVE INFORMATION ON INDEPENDENT REVIEW ENTITIES, TOGETHER WITH ANY RECOMMENDATIONS MADE BY THE HEALTH COVERAGE PLAN AS TO THE APPROPRIATE INDEPENDENT REVIEW ENTITY;
(b) A REQUEST THAT WITHIN FIVE BUSINESS DAYS THE COVERED PERSON NOTIFY THE PLAN IN WRITING STATING THE PERSON'S CHOICE OF INDEPENDENT REVIEW ENTITY TO REVIEW THE PERSON'S REQUEST FOR COVERAGE. IF A COVERED INDIVIDUAL FAILS TO CHOOSE AN INDEPENDENT REVIEW ENTITY THE PLAN MAY DO SO.
(c) A STATEMENT THAT THE COVERED PERSON IS RESPONSIBLE FOR THE PAYMENT OF FIFTY DOLLARS TO OFFSET A PORTION OF THE COST OF THE INDEPENDENT REVIEW PAYABLE BEFORE THE COMMENCEMENT OF THE INDEPENDENT REVIEW PROCESS; EXCEPT THAT THIS PARAGRAPH (c) SHALL NOT APPLY TO ANY MEDICAID RECIPIENT ENROLLED IN A HEALTH BENEFIT PLAN UNDER CONTRACT WITH THE MEDICAID PROGRAM. A COVERED PERSON SHALL NOT BE ENTITLED TO ANY REFUND OF THE PAYMENT REQUIRED BY THIS PARAGRAPH (c). ANY COSTS OF AN INDEPENDENT REVIEW PROCESS IN EXCESS OF ONE HUNDRED DOLLARS SHALL BE PAID BY THE HEALTH BENEFIT PLAN; AND
(d) AUTHORIZATIONS FOR EXECUTION BY THE COVERED PERSON IN ORDER TO GAIN ACCESS TO MEDICAL RECORDS NECESSARY FOR THE CONDUCT OF THE MEDICAL REVIEW.
(12) (a) THE HEALTH COVERAGE PLAN SHALL PROVIDE TO THE INDEPENDENT REVIEW ENTITY A COPY OF THE FOLLOWING DOCUMENTS WITHIN FIVE BUSINESS DAYS AFTER THE HEALTH BENEFIT PLAN'S RECEIPT OF A COMPLETED REQUEST BY A COVERED PERSON OR A COVERED PERSON'S PHYSICIAN FOR AN INDEPENDENT REVIEW; EXCEPT THAT, WITH RESPECT TO A REQUEST FOR AN EXPEDITED REVIEW, SUCH DOCUMENTS SHALL BE PROVIDED WITHIN TWO BUSINESS DAYS:
(I) ANY INFORMATION SUBMITTED TO THE PLAN BY A COVERED PERSON OR THE COVERED PERSON'S PHYSICIAN IN SUPPORT OF THE COVERED PERSON'S REQUEST FOR COVERAGE UNDER THE PLAN'S PROCEDURES. THE INDEPENDENT REVIEW ENTITY SHALL MAINTAIN THE CONFIDENTIALITY OF ANY MEDICAL RECORDS SUBMITTED PURSUANT TO THIS SUBSECTION (12).
(II) A COPY OF THE CONTRACTUAL PROVISIONS UPON WHICH THE DENIAL OF COVERAGE WAS BASED, ANY OTHER RELEVANT DOCUMENTS USED BY THE PLAN TO DETERMINE WHETHER THE PROPOSED SERVICE OR TREATMENT SHOULD BE COVERED, AND A COPY OF ANY DENIAL LETTERS ISSUED BY THE PLAN CONCERNING THE INDIVIDUAL CASE UNDER REVIEW. THE HEALTH COVERAGE PLAN SHALL PROVIDE, UPON REQUEST TO THE COVERED INDIVIDUAL REQUESTING AN INDEPENDENT REVIEW, ALL RELEVANT INFORMATION SUPPLIED TO THE INDEPENDENT REVIEW ENTITY THAT IS NOT CONFIDENTIAL OR PRIVILEGED UNDER STATE OR FEDERAL LAW CONCERNING THE INDIVIDUAL CASE UNDER REVIEW.
(b) THE INDEPENDENT REVIEW ENTITY SHALL NOTIFY THE COVERED PERSON, THE COVERED PERSON'S PHYSICIAN, AND THE HEALTH COVERAGE PLAN OF ANY ADDITIONAL MEDICAL INFORMATION REQUIRED TO CONDUCT THE REVIEW WITHIN FIVE BUSINESS DAYS AFTER RECEIPT OF THE DOCUMENTATION REQUIRED PURSUANT TO THIS SECTION; EXCEPT THAT, IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT REVIEW ENTITY SHALL NOTIFY SUCH PERSONS WITHIN THREE BUSINESS DAYS AFTER THE RECEIPT OF SUCH DOCUMENTATION. THE COVERED PERSON OR THE COVERED PERSON'S PHYSICIAN SHALL SUBMIT THE ADDITIONAL INFORMATION, OR AN EXPLANATION OF WHY THE ADDITIONAL INFORMATION IS NOT BEING SUBMITTED, TO THE INDEPENDENT REVIEW ENTITY AND THE PLAN WITHIN FIVE BUSINESS DAYS AFTER THE RECEIPT OF SUCH A REQUEST. THE HEALTH COVERAGE PLAN MAY, AT ITS DISCRETION, DETERMINE THAT ADDITIONAL INFORMATION PROVIDED BY THE INSURED OR THE INSURED'S PHYSICIAN JUSTIFIES A RECONSIDERATION OF ITS DENIAL OF COVERAGE, AND A SUBSEQUENT DECISION BY THE HEALTH BENEFIT PLAN TO PROVIDE COVERAGE SHALL TERMINATE THE INDEPENDENT REVIEW UPON NOTIFICATION TO THE INDEPENDENT REVIEW ENTITY.
(13) (a) THE INDEPENDENT REVIEW ENTITY SHALL SUBMIT THE EXPERT DETERMINATION TO THE HEALTH BENEFIT PLAN, THE COVERED PERSON, AND THE COVERED PERSON'S PHYSICIAN WITHIN THIRTY CALENDAR DAYS AFTER THE RECEIPT OF THE REQUEST FOR REVIEW; EXCEPT THAT, AT THE REQUEST OF THE EXPERT REVIEWER, SUCH DEADLINE SHALL BE EXTENDED BY UP TO SEVENTYTWO HOURS FOR THE CONSIDERATION OF ADDITIONAL INFORMATION REQUIRED PURSUANT TO THIS SECTION. IN THE CASE OF AN EXPEDITED REVIEW THE DETERMINATIONS SHALL BE SUBMITTED WITHIN FIVE DAYS AFTER THE RECEIPT OF THE REQUEST FOR REVIEW ; EXCEPT THAT, AT THE REQUEST OF THE EXPERT REVIEWER, THE DEADLINE SHALL BE EXTENDED FOR FORTYEIGHT HOURS FOR THE CONSIDERATION OF ADDITIONAL INFORMATION REQUIRED PURSUANT TO THIS SECTION.
(b) THE EXPERT REVIEWER'S DETERMINATION SHALL BE IN WRITING AND STATE THE REASONS THE REQUESTED TREATMENT OR SERVICE SHOULD OR SHOULD NOT BE COVERED. THE EXPERT'S DETERMINATIONS SHALL SPECIFICALLY CITE THE RELEVANT PROVISIONS IN THE HEALTH BENEFIT PLAN DOCUMENTATION, THE COVERED PERSON'S SPECIFIC MEDICAL CONDITION, AND THE RELEVANT DOCUMENTS PROVIDED PURSUANT TO THIS SECTION TO SUPPORT THE EXPERT'S DETERMINATION.
(c) DETERMINATIONS SHALL ALSO INCLUDE:
(I) THE TITLES AND QUALIFYING CREDENTIALS OF THE PERSONS CONDUCTING THE REVIEW;
(II) A STATEMENT OF THE UNDERSTANDING OF THE PERSONS CONDUCTING THE REVIEW OF THE NATURE OF THE GRIEVANCE AND ALL PERTINENT FACTS;
(III) THE RATIONALE FOR THE DECISION;
(IV) REFERENCE TO EVIDENCE OR DOCUMENTATION CONSIDERED IN MAKING THE DETERMINATION; AND
(V) IN CASES INVOLVING A DETERMINATION ADVERSE TO THE COVERED PERSON, THE INSTRUCTIONS FOR REQUESTING A WRITTEN STATEMENT OF THE CLINICAL RATIONALE, INCLUDING THE CLINICAL REVIEW CRITERIA USED TO MAKE THE DETERMINATION.
(14) A DETERMINATION OF THE EXPERT REVIEWER IN FAVOR OF THE COVERED INDIVIDUAL SHALL BE BINDING ON THE HEALTH COVERAGE PLAN. A DETERMINATION IN FAVOR OF THE HEALTH COVERAGE PLAN SHALL CREATE A REBUTTABLE PRESUMPTION IN ANY SUBSEQUENT ACTION THAT THE HEALTH BENEFIT PLAN'S COVERAGE DETERMINATION WAS APPROPRIATE.
(15) WHERE AN EXPERT DETERMINATION IS MADE IN FAVOR OF THE COVERED INDIVIDUAL, COVERAGE FOR THE TREATMENT AND SERVICES REQUIRED UNDER THIS SECTION SHALL BE PROVIDED SUBJECT TO THE TERMS AND CONDITIONS APPLICABLE TO BENEFITS UNDER THE HEALTH BENEFIT PLAN.
(16) AN INDEPENDENT REVIEW ENTITY AND AN EXPERT REVIEWER ASSIGNED BY THE INDEPENDENT REVIEW ENTITY TO CONDUCT A REVIEW PURSUANT TO THIS SECTION SHALL NOT BE LIABLE FOR DAMAGES ARISING FROM THE DETERMINATIONS MADE PURSUANT TO THIS SECTION. THIS SUBSECTION (16) SHALL NOT APPLY TO AN ACT OR OMISSION OF THE INDEPENDENT REVIEW ENTITY THAT IS MADE IN BAD FAITH OR INVOLVES GROSS NEGLIGENCE.
(17) A HEALTH COVERAGE PLAN MAY REQUIRE A SURETY BOND TO INDEMNIFY THE HEALTH BENEFIT PLAN FOR THE INDEPENDENT REVIEW ENTITY'S NONCOMPLIANCE WITH THIS SECTION.
SECTION 2. 1031104 (1), Colorado Revised Statutes, is amended BY THE ADDITION OF A NEW PARAGRAPH to read:
1031104. Unfair methods of competition and unfair or deceptive acts or practices. (1) The following are defined as unfair methods of competition and unfair or deceptive acts or practices in the business of insurance:
(z) VIOLATING ANY PROVISION OF SECTION 1016113.5.
SECTION 3. Effective date applicability. This act shall take effect January 1, 1999, and shall apply to denials of coverage made 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.