Bulletin No. B-4.20
Annual Report of Internal and Independent External Review Appeals
I.
Background and Purpose
The purpose of this bulletin is to provide guidance to health carriers for the required reporting of
the number and outcomes of internal appeals those specified in § 10-16-113.7, C.R.S. and to
provide the number and outcomes of independent external review appeals. This bulletin provides
a description of the information required to be reported.
Bulletins are the Colorado Division of Insurance’s (“Division”) interpretations of existing insurance
law or general statements of Division policy. Bulletins themselves establish neither binding norms
nor finally determine issues or rights.
II.
Applicability and Scope
This bulletin is intended for use by all regulated entities that are licensed in Colorado to issue
health coverage plans as defined in § 10-16-102(22.5), C.R.S.
III.
Division Position
A.
Section 10-16-113, C.R.S., provides Colorado consumers with access to an appeals
process for certain denials of health benefits which includes a first level appeal with the
carrier and the ability to request a second level appeal, at their discretion, if the denial is
upheld by the carrier at the completion of the first level appeal review. Colorado
consumers can request an independent external review pursuant to § 10-16-113.5,
C.R.S., at the completion of the first level appeal or at the completion of the voluntary
second level appeal review.
B.
Existing law requires all carriers to report the number and outcome of second level internal
appeals pursuant to § 10-16-113, C.R.S., and Colorado Insurance Regulation 4-2-17 to
the Division by February 1 of each year. The Division expects this annual report to include
information on second level internal appeals that were conducted during the previous
calendar year. If a carrier had no second level appeals during the specified calendar year,
the carrier shall still file the report indicating no second level appeals were provided.
C.
The Division is also requesting that each carrier report the number of first level internal
appeals and the number of independent external reviews that were requested and
completed in the previous calendar year. If the carrier had no first level internal appeals or
no independent external review appeals during the specified calendar year, the carrier
shall still file the report indicating no first level internal appeals or no independent external
review appeal requests were completed, as appropriate.
D.
Carriers that are licensed to sell health coverage plans but which have no Colorado
covered lives must still complete the report to provide that information to the Division.
E.
The information required to be reported for first level appeals is:
1. Total number of appeals requested and completed in the specified calendar year;
2. Number of these appeals where the carrier’s position was upheld;
3. Number of these appeals decided in favor of the consumer;
4. Number of these appeals with a mixed disposition;
5. Number of these appeals withdrawn prior to completion.
F.
The information required to be reported for second level appeals is:
1. Total number of appeals requested and completed in the specified calendar year;
2. Number of these appeals where the carrier’s position was upheld;
3. Number of these appeals decided in favor of the consumer;
4. Number of these appeals with a mixed disposition;
5. Number of these appeals withdrawn prior to completion.
G.
The information required to be reported for independent external review appeals is:
1. Total number of appeals requested and completed in the specified calendar year;
2. Number of these appeals where the carrier’s position was upheld;
3. Number of these appeals decided in favor of the consumer;
4. Number of these appeals with a mixed disposition;
5. Number of these appeals withdrawn prior to completion.
H.
The Division will provide an electronic link on its website which will allow each carrier to
report the required data in an electronic format. Paper reports will no longer be accepted.
I.
Pursuant to § 10-3-109(2), C.R.S., failure to file this statutorily-required report by February 1
may result in a late penalty not to exceed $100 per day and any applicable surcharges.
IV.
Additional Division Resources
A.
For More Information
Colorado Division of Insurance
Consumer Affairs, Life and Health Section
1560 Broadway, Suite 850
Denver, CO 80202
Tel. 303-894-7490 Toll-free (in state): 800-930-3745
Internet: dora.colorado.gov/doi
B.
Related Division Regulations
Colorado Insurance Regulation 4-2-17
Colorado Insurance Regulation 4-2-21
V.
History
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Originally issued as bulletin 05-05, July 8, 2005.
Amended as bulletin 05-05, December 22, 2006.
Reissued May 8, 2007.
Reissued November 20, 2009.
Reissued February 8, 2012
Reissued January 2, 2013