Second Regular Session
Seventy-fourth General Assembly
STATE OF COLORADO
ENGROSSED
This Version Includes All Amendments Adopted
on Second Reading in the House of Introduction
LLS NO. 24-0202.01 Christy Chase x2008
HOUSE BILL 24-1149
House Committees Senate Committees
Health & Human Services
Appropriations
A BILL FOR AN ACT
C
ONCERNING MODIFICATIONS TO REQUIREMENTS FOR PRIOR101
AUTHORIZATION OF BENEFITS UNDER HEALTH BENEFIT
PLANS,102
AND, IN CONNECTION THEREWITH, MAKING AN APPROPRIATION.103
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
.)
With regard to prior authorization requirements imposed by
carriers, private utilization review organizations (organizations), and
pharmacy benefit managers (PBMs) for certain health-care services and
prescription drug benefits covered under a health benefit plan, the bill
requires carriers, organizations, and PBMs, as applicable, to adopt a
HOUSE
Amended 2nd Reading
March 8, 2024
HOUSE SPONSORSHIP
Bird and Frizell, Amabile, Armagost, Bacon, Boesenecker, Bradfield, Clifford, deGruy
Kennedy, Duran, English, Froelich, Garcia, Hamrick, Hartsook, Hernandez, Jodeh, Kipp,
Lieder, Lindstedt, Mabrey, McLachlan, Ortiz, Rutinel, Sirota, Snyder, Soper, Taggart, Titone,
Valdez, Velasco, Weinberg, Willford, Wilson, Young
SENATE SPONSORSHIP
Roberts and Kirkmeyer, Ginal, Baisley, Bridges, Buckner, Coleman, Cutter, Gonzales,
Hansen, Hinrichsen, Kolker, Liston, Marchman, Michaelson Jenet, Mullica, Pelton R., Rich,
Van Winkle, Will, Winter F., Zenzinger
Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.
Capital letters or bold & italic numbers indicate new material to be added to existing law.
Dashes through the words or numbers indicate deletions from existing law. program, in consultation with participating providers, to eliminate or
substantially modify prior authorization requirements in a manner that
removes administrative burdens on qualified providers and their patients
with regard to certain health-care services, prescription drugs, or related
benefits based on specified criteria. Additionally, a carrier or organization
is prohibited from denying a claim for a health-care procedure a provider
provides, in addition or related to an approved surgical procedure, under
specified circumstances or from denying an initially approved surgical
procedure on the basis that the provider provided an additional or a
related health-care procedure.
The bill extends the duration of an approved prior authorization for
a health-care service or prescription drug benefit from 180 days to a
calendar year.
Carriers are required to post, on their public-facing websites,
specified information regarding:
! The number of prior authorization requests that are
approved, denied, and appealed;
! The number of prior authorization exemptions or
alternatives to prior authorization requirements provided
pursuant to a program developed and offered by the carrier,
an organization, or a PBM; and
! The prior authorization requirements as applied to
prescription drug formularies for each health benefit plan
the carrier or PBM offers.
The bill applies to conduct occurring on or after January 1, 2026.
Be it enacted by the General Assembly of the State of Colorado:1
SECTION 1. Legislative declaration. (1) The general assembly2
finds and declares that:3
(a) Timely access to necessary health care is of vital importance4
to Coloradans;5
(b) The provider-patient relationship is paramount and should not6
be subject to intrusion by a third party;7
(c) Coloradans and their health-care providers deserve easy access8
to information regarding health insurance benefits so that, together, they9
can determine the proper course of treatment;10
(d) Utilization management processes, such as prior authorization,11
1149-2- delay care, which, according to thirty-four percent of physicians surveyed1
nationally, leads to serious adverse events for their patients, including2
hospitalization, permanent disability, or even death;3
(e) These outcomes due to delays in timely accessing services and4
prescriptions are known to disproportionately impact historically5
marginalized populations, such as Black and Hispanic patients, furthering6
health disparities in the state;7
(f) Surveys have found that over sixty percent of physicians also8
report that it is difficult to determine whether a prescription medication9
or medical service requires prior authorization, adding burdensome10
administrative steps for health-care providers and patients to understand11
requirements for accessing necessary medical services or prescriptions;12
and13
(g) Health systems spend an average of twenty dollars, for a14
primary care visit, to two hundred fifteen dollars, for an inpatient surgical15
procedure, on administrative tasks to navigate insurer utilization16
management processes like processing prior authorization requests.17
(2) Therefore, it is the intent of the general assembly, by18
establishing transparent prescription formularies and enabling access to19
prior authorization requirements at the point of care delivery; requiring20
posting of data on prior authorization practices; and requiring carriers,21
private utilization review organizations, and pharmacy benefit managers22
to adopt a program that streamlines the administrative process for23
qualifying health-care providers who satisfy certain objective criteria24
regarding quality and appropriateness of care and specialty area and25
experience, to:26
(a) Ensure Coloradans have equitable access to medically27
1149
-3- necessary care;1
(b) Reduce administrative burdens and costs borne by health-care2
providers; and3
(c) Reduce overall costs to the health-care system.4
SECTION 2. In Colorado Revised Statutes, 10-16-112.5, amend5
(2)(a), (2)(c), (3)(a)(I), (3)(c)(II), (4)(b), (5)(a), (6), and (7)(e); and add6
(3)(c)(III), (3.5), and (4)(c) as follows:7
10-16-112.5. Prior authorization for health-care services -8
disclosures and notice - determination deadlines - criteria - limits and9
exceptions - definitions - rules - enforcement. (2) Disclosure of10
requirements - notice of changes. (a) (I) A carrier shall make POST11
current prior authorization requirements and restrictions, including12
written, clinical criteria, readily accessible on the carrier's PUBLIC-FACING13
website
IN A READILY ACCESSIBLE, STANDARDIZED, SEARCHABLE FORMAT.14
The prior authorization requirements must be described in detail and in15
clear and easily understandable language.16
(II) If a carrier contracts with a private utilization review17
organization to perform prior authorization for health-care services, the18
organization shall provide its prior authorization requirements and19
restrictions, as required by this subsection (2), to the carrier with whom
20
WHICH the organization contracted, and that carrier shall post the21
organization's prior authorization requirements and restrictions on its22
PUBLIC-FACING website IN THE MANNER REQUIRED BY SUBSECTION23
(2)(a)(I)
OF THIS SECTION.24
(III) When posting prior authorization requirements and
25
restrictions pursuant to this subsection (2)(a) or subsection (2)(b) of this26
section, a carrier is neither required to post nor prohibited from posting27
1149
-4- the prior authorization requirements and restrictions on a public-facing1
portion of its website.2
(c) (I) A carrier shall post, on a public-facing portion of its3
website, data regarding approvals and denials of prior authorization4
requests, including requests for drug benefits pursuant to section5
10-16-124.5, in a readily accessible,
STANDARDIZED, SEARCHABLE format6
and that include the following: categories, in the aggregate:
7
(A) Provider specialty THE TOTAL NUMBER OF PRIOR8
AUTHORIZATION REQUESTS RECEIVED IN THE IMMEDIATELY PRECEDING9
CALENDAR YEAR IN EACH OF THE FOLLOWING CATEGORIES OF SERVICES :10
M
EDICAL PROCEDURES; DIAGNOSTIC TESTS AND DIAGNOSTIC IMAGES ;11
PRESCRIPTION DRUGS; AND ALL OTHER CATEGORIES OF HEALTH -CARE12
SERVICES OR DRUG BENEFITS FOR WHICH A PRIOR AUTHORIZATION13
REQUEST WAS RECEIVED;14
(B) Medication or diagnostic test or procedure
THE TOTAL15
NUMBER OF PRIOR AUTHORIZATION REQUESTS THAT WERE APPROVED IN16
EACH OF THE CATEGORIES SPECIFIED IN SUBSECTION (2)(c)(I)(A) OF THIS17
SECTION;18
(B.5) THE TOTAL NUMBER OF PRIOR AUTHORIZATION REQUESTS19
FOR WHICH AN ADVERSE DETERMINATION WAS ISSUED AND THE SERVICE20
WAS DENIED IN EACH OF THE CATEGORIES SPECIFIED IN SUBSECTION21
(2)(c)(I)(A)
OF THIS SECTION;
22
(C) THE reason for THE denial IN EACH OF THE CATEGORIES23
SPECIFIED IN SUBSECTION (2)(c)(I)(A) OF THIS SECTION, WITH THE DENIAL24
REASONS SORTED BY CATEGORIES DEFINED BY RULE ; and25
(D) Denials specified under subsection (2)(c)(I)(C) of this section26
that are overturned on appeal IN EACH OF THE CATEGORIES SPECIFIED IN27
1149
-5- SUBSECTION (2)(c)(I)(A) OF THIS SECTION, THE TOTAL NUMBER OF1
ADVERSE DETERMINATIONS THAT WERE APPEALED AND WHETHER THE2
DETERMINATION WAS UPHELD OR REVERSED ON APPEAL .3
(II) An organization
OR PBM that provides prior authorization for4
a carrier shall provide the data specified in subsection (2)(c)(I) of this5
section to the carrier with whom
WHICH the organization OR PBM6
contracted, and the carrier shall post the organization's
OR PBM'S data on7
its
PUBLIC-FACING website IN THE MANNER REQUIRED BY SUBSECTION8
(2)(c)(I)
OF THIS SECTION.9
(III) Carriers and organizations shall use the data specified in this10
subsection (2)(c) to refine and improve their utilization management11
programs. C
ARRIERS AND ORGANIZATIONS SHALL REVIEW THE LIST OF12
MEDICAL PROCEDURES , DIAGNOSTIC TESTS AND DIAGNOSTIC IMAGES ,13
PRESCRIPTION DRUGS, AND OTHER HEALTH-CARE SERVICES FOR WHICH THE14
CARRIER OR ORGANIZATION REQUIRES PRIOR AUTHORIZATION AT LEAST15
ANNUALLY AND SHALL ELIMINATE THE PRIOR AUTHORIZATION16
REQUIREMENTS FOR THOSE PROCEDURES , DIAGNOSTIC TESTS AND17
DIAGNOSTIC IMAGES, PRESCRIPTION DRUGS, OR OTHER HEALTH-CARE18
SERVICES FOR WHICH PRIOR AUTHORIZATION
NEITHER PROMOTES19
HEALTH-CARE QUALITY OR EQUITY NOR SUBSTANTIALLY REDUCES20
HEALTH-CARE SPENDING. EACH CARRIER AND ORGANIZATION SHALL21
ANNUALLY ATTEST TO THE COMMISSIONER THAT IT HAS COMPLETED THE22
REVIEW REQUIRED BY THIS SUBSECTION (2)(c)(III) AND HAS ELIMINATED23
PRIOR AUTHORIZATION REQUIREMENTS CONSISTENT WITH THE24
REQUIREMENTS OF THIS SUBSECTION (2)(c)(III).25
(IV) A
CARRIER SHALL POST, ON A PUBLIC-FACING PORTION OF ITS26
WEBSITE, IN A READILY ACCESSIBLE , STANDARDIZED, SEARCHABLE27
1149
-6- FORMAT, DATA ON THE NUMBER OF EXEMPTIONS FROM PRIOR1
AUTHORIZATION REQUIREMENTS OR ALTERNATIVES TO PRIOR2
AUTHORIZATION REQUIREMENTS PROVIDED PURSUANT TO A PROGRAM3
ADOPTED BY THE CARRIER , ORGANIZATION, OR PBM PURSUANT TO4
SUBSECTION (4)(b)(II) OF THIS SECTION OR SECTION 10-16-124.5 (5.5), AS5
APPLICABLE. THE CARRIER SHALL INCLUDE THE FOLLOWING DATA :6
(A) T
HE NUMBER OF PROVIDERS OFFERED AN EXEMPTION OR7
ALTERNATIVE PROGRAM , INCLUDING THEIR SPECIALTY AREAS;8
(B) T
HE NUMBER AND CATEGORIZED TYPES OF EXEMPTIONS OR9
ALTERNATIVE PROGRAMS OFFERED TO PROVIDERS ; AND10
(C) T
HE PRESCRIPTION DRUG, DIAGNOSTIC TEST, PROCEDURE, OR11
OTHER HEALTH-CARE SERVICE FOR WHICH AN EXEMPTION OR12
ALTERNATIVE PROGRAM WAS OFFERED .13
(V) T
HE COMMISSIONER SHALL ADOPT RULES
TO:14
(A) IMPLEMENT SUBSECTIONS (2)(c)(I) AND (2)(c)(IV) OF THIS15
SECTION TO ENSURE THAT THE DATA FIELDS REQUIRED TO BE POSTED16
PURSUANT TO SUBSECTIONS (2)(c)(I) AND (2)(c)(IV) OF THIS SECTION ARE17
PRESENTED CONSISTENTLY BY CARRIERS; AND18
(B) DEFINE CATEGORIES OF PRIOR AUTHORIZATION REQUEST19
DENIALS FOR PURPOSES OF SUBSECTION (2)(c)(I)(C) OF THIS SECTION.20
(3) Nonurgent and urgent health-care services - timely21
determination - notice of determination - deemed approved.22
(a) Except as provided in subsection (3)(b) of this section, a prior23
authorization request is deemed granted if a carrier or organization fails24
to:25
(I) (A) Notify the provider and covered person, within five26
business days after receipt of the request, that the request is approved,27
1149
-7- denied, or incomplete and INDICATE: If DENIED, WHAT RELEVANT1
ALTERNATIVE SERVICES OR TREATMENTS MAY BE A COVERED BENEFIT OR2
ARE REQUIRED BEFORE APPROVAL OF THE DENIED SERVICE OR3
TREATMENT; OR IF incomplete, indicate the specific additional4
information, consistent with criteria posted pursuant to subsection (2)(a)5
of this section, that is required to process the request; or6
(B) Notify the provider and covered person, within five business7
days after receiving the additional information required by the carrier or8
organization pursuant to subsection (3)(a)(I)(A) of this section, that the9
request is approved or denied AND, IF DENIED, INDICATE WHAT RELEVANT10
ALTERNATIVE SERVICES OR TREATMENTS MAY BE A COVERED BENEFIT OR11
ARE REQUIRED BEFORE APPROVAL OF THE DENIED SERVICE OR12
TREATMENT; and13
(c) (II) If the carrier or organization denies a prior authorization14
request based on a ground specified in section 10-16-113 (3)(a), the15
notification is subject to the requirements of section 10-16-113 (3)(a) and16
commissioner rules adopted pursuant to that section and must:17
(A) Include information concerning whether the carrier or18
organization requires an alternative treatment, test, procedure, or19
medication
AND WHAT ALTERNATIVE SERVICES OR
TREATMENTS WOULD20
BE APPROVED AS A COVERED BENEFIT UNDER THE HEALTH BENEFIT PLAN;21
OR22
(B) IN THE CASE OF THE DENIAL OF A PRIOR AUTHORIZATION23
REQUEST FOR A PRESCRIPTION DRUG, SPECIFY WHICH PRESCRIPTION DRUGS24
AND DOSAGES IN THE SAME CLASS AS THE PRESCRIPTION DRUG FOR WHICH25
THE PRIOR AUTHORIZATION REQUEST WAS DENIED ARE COVERED26
PRESCRIPTION DRUGS UNDER THE HEALTH BENEFIT PLAN .27
1149
-8- (III) A CARRIER'S, ORGANIZATION'S, OR PHARMACY BENEFIT1
MANAGER'S COMPLIANCE WITH THIS SUBSECTION (3)(c)(II) DOES NOT2
CONSTITUTE THE PRACTICE OF MEDICINE .3
(3.5) (a) STARTING JANUARY 1, 2027, A CARRIER OR4
ORGANIZATION SHALL HAVE, MAINTAIN, AND USE A PRIOR AUTHORIZATION5
APPLICATION PROGRAMMING INTERFACE THAT AUTOMATES THE PRIOR6
AUTHORIZATION PROCESS TO ENABLE A PROVIDER TO :7
(I) DETERMINE WHETHER PRIOR AUTHORIZATION IS REQUIRED FOR8
A HEALTH-CARE SERVICE;9
(II) IDENTIFY PRIOR AUTHORIZATION INFORMATION AND10
DOCUMENTATION REQUIREMENTS ; AND11
(III) FACILITATE THE EXCHANGE OF PRIOR AUTHORIZATION12
REQUESTS AND DETERMINATIONS FROM THE PROVIDER'S ELECTRONIC13
HEALTH RECORDS OR PRACTICE MANAGEMENT SYSTEMS THR OUGH SECURE14
ELECTRONIC TRANSMISSION.15
(b) A CARRIER'S OR ORGANIZATION'S APPLICATION PROGRAMMING16
INTERFACE MUST MEET THE MOST RECENT STANDARDS AND17
IMPLEMENTATION SPECIFICATIONS ADOPTED BY THE SECRETARY OF THE18
UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES AS19
SPECIFIED IN 45 CFR 170.215 (a).20
(c) IF A PROVIDER SUBMITS A PRIOR AUTHORIZATION REQUEST21
THROUGH THE CARRIER'S OR ORGANIZATION'S APPLICATION PROGRAMMING22
INTERFACE, THE CARRIER OR ORGANIZATION SHALL ACCEPT AND RESPOND23
TO THE REQUEST THROUGH THE INTERFACE .24
(4) Criteria, limits, and exceptions. (b) (I) Carriers and25
organizations shall consider limiting the use of prior authorization to26
providers whose prescribing or ordering patterns differ significantly from27
1149
-9- the patterns of their peers after adjusting for patient mix and other1
relevant factors and present opportunities for improvement in adherence2
to the carrier's or organization's prior authorization requirements.3
(II) (A) NO LATER THAN JANUARY 1, 2026, a carrier or AN4
organization may offer providers with a history of adherence to the5
carrier's or organization's prior authorization requirements at least one6
alternative to prior authorization, including an exemption from prior7
authorization requirements for a provider that has at least an eighty8
percent approval rate of prior authorization requests over the immediately9
preceding twelve months. SHALL ADOPT A PROGRAM , DEVELOPED IN10
CONSULTATION WITH PROVIDERS PARTICIPATING WITH THE CARRIER , TO11
ELIMINATE OR SUBSTANTIALLY MODIFY PRIOR AUTHORIZATION12
REQUIREMENTS IN A MANNER THAT REMOVES THE ADMINISTRATIVE13
BURDEN FOR QUALIFIED PROVIDERS , AS DEFINED UNDER THE PROGRAM ,14
AND THEIR PATIENTS FOR CERTAIN HEALTH-CARE SERVICES AND RELATED15
BENEFITS BASED ON ANY OF THE FOLLOWING :16
(A) T
HE PERFORMANCE OF PROVIDERS WITH RESPECT TO17
ADHERENCE TO NATIONALLY RECOGNIZED , EVIDENCE-BASED MEDICAL18
GUIDELINES, APPROPRIATENESS, EFFICIENCY, AND OTHER QUALITY19
CRITERIA; AND20
(B) P
ROVIDER SPECIALTY, EXPERIENCE, OR OTHER OBJECTIVE21
FACTORS; EXCEPT THAT ELIGIBILITY FOR THE PROGRAM MUST NOT BE22
LIMITED BY PROVIDER SPECIALTY.23
(III) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (4)(b)(II)24
OF THIS SECTION:25
(A) M
UST NOT REQUIRE QUALIFIED PROVIDERS TO REQUEST26
PARTICIPATION IN THE PROGRAM; AND27
1149
-10- (B) MAY INCLUDE LIMITING THE USE OF PRIOR AUTHORIZATION TO1
PROVIDERS WHOSE PRESCRIBING OR ORDERING PATTERNS DIFFER2
SIGNIFICANTLY FROM THE PATTERNS OF THEIR PEERS AFTER ADJUSTING3
FOR PATIENT MIX AND OTHER RELEVANT FACTORS AND IN ORDER TO4
PRESENT THOSE PROVIDERS WITH OPPORTUNITIES FOR IMPROVEMENT IN5
ADHERENCE TO THE CARRIER'S OR ORGANIZATION'S PRIOR AUTHORIZATION6
REQUIREMENTS.7
(IV) At least annually, a carrier or
AN organization shall:8
(A) Reexamine a provider's prescribing or ordering patterns; and
9
(B) Reevaluate the provider's status for exemption from or other10
alternative to prior authorization requirements OR FOR INCLUSION IN THE11
PROGRAM DEVELOPED pursuant to this subsection (4)(b)(II) OF THIS12
SECTION; AND13
(B) (C) The carrier or organization shall inform NOTIFY the14
provider of the provider's
STATUS FOR exemption status and provide
15
information on the data considered as part of its reexamination of the16
provider's prescribing or ordering patterns for the twelve-month period of17
review OR INCLUSION IN THE PROGRAM.18
(V) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (4)(b)(II)19
OF THIS SECTION MUST INCLUDE PROCEDURES FOR A PROVIDER TO20
REQUEST:21
(A) A
N EXPEDITED, INFORMAL RESOLUTION OF A CARRIER'S OR AN22
ORGANIZATION'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE23
PROGRAM; AND24
(B) I
F THE MATTER IS NOT RESOLVED THROUGH INFORMAL25
RESOLUTION, BINDING ARBITRATION AS SPECIFIED IN SUBSECTION26
(4)(b)(VI) OF THIS SECTION.27
1149
-11- (VI) IF A PROVIDER REQUESTS BINDING ARBITRATION PURSUANT1
TO THE PROCEDURES A CARRIER OR AN ORGANIZATION DEVELOPS UNDER2
SUBSECTION (4)(b)(V)(B) OF THIS SECTION, THE FOLLOWING PROVISIONS3
GOVERN THE ARBITRATION PROCEDURE :4
(A) THE PROVIDER AND CARRIER OR ORGANIZATION SHALL5
JOINTLY SELECT AN ARBITRATOR FROM THE LIST OF ARBITRATORS6
APPROVED PURSUANT TO SECTION 10-16-704 (15)(b). NEITHER THE7
PROVIDER NOR THE CARRIER OR ORGANIZATION IS REQUIRED TO NOTIFY8
THE DIVISION OF THE ARBITRATION OR OF THE SELECTED ARBITRATOR .9
(B) THE SELECTED ARBITRATOR SHALL DETERMINE THE10
PROVIDER'S ELIGIBILITY TO PARTICIPATE IN THE CARRIER 'S OR11
ORGANIZATION'S PROGRAM BASED ON THE PROGRAM CRITERIA DEVELOPED12
PURSUANT TO SUBSECTION (4)(b)(II) OF THIS SECTION;13
(C) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR14
ACCEPTS THE MATTER , THE PROVIDER AND THE CARRIER OR15
ORGANIZATION SHALL SUBMIT TO THE ARBITRATOR WRITTEN MATERIALS16
IN SUPPORT OF THEIR RESPECTIVE POSITIONS;17
(D) THE ARBITRATOR MAY RENDER A DECISION BASED ON THE18
WRITTEN MATERIALS SUBMITTED PURSUANT TO SUBSECTION (4)(b)(VI)(C)19
OF THIS SECTION OR MAY SCHEDULE A HEARING, LASTING NOT LONGER20
THAN ONE DAY, FOR THE PROVIDER AND CARRIER OR ORGANIZATION TO21
PRESENT EVIDENCE;22
(E) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR23
RECEIVES THE WRITTEN MATERIALS OR, IF A HEARING IS CONDUCTED, THE24
DATE OF THE HEARING, THE ARBITRATOR SHALL ISSUE A WRITTEN25
DECISION STATING WHETHER THE PROVIDER IS ELIGIBLE FOR THE26
PROGRAM; AND27
1149
-12- (F) IF THE ARBITRATOR OVERTURNS THE CARRIER 'S OR1
ORGANIZATION'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE2
PROGRAM, THE CARRIER OR ORGANIZATION SHALL PAY THE ARBITRATOR'S3
FEES AND COSTS, AND IF THE ARBITRATOR AFFIRMS THE CARRIER'S OR4
ORGANIZATION'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE5
PROGRAM, THE PROVIDER SHALL PAY THE ARBITRATOR'S FEES AND COSTS.6
7
(c) (I) WHEN A CARRIER OR AN ORGANIZATION APPROVES A PRIOR8
AUTHORIZATION REQUEST FOR A SURGICAL PROCEDURE FOR WHICH PRIOR9
AUTHORIZATION IS REQUIRED, THE CARRIER OR ORGANIZATION SHALL NOT10
DENY A CLAIM FOR AN ADDITIONAL OR A RELATED HEALTH -CARE11
PROCEDURE IDENTIFIED DURING THE AUTHORIZED SURGICAL PROCEDURE12
IF:13
(A) T
HE PROVIDER, WHILE PROVIDING THE APPROVED SURGICAL14
PROCEDURE TO TREAT THE COVERED PERSON , DETERMINES, IN15
ACCORDANCE WITH GENERALLY ACCEPTED STANDARDS OF MEDICAL16
PRACTICE, THAT PROVIDING A RELATED HEALTH -CARE PROCEDURE,17
INSTEAD OF OR IN ADDITION TO THE APPROVED SURGICAL PROCEDURE , IS18
MEDICALLY NECESSARY AS PART OF THE TREATMENT OF THE COVERED19
PERSON AND THAT, IN THE PROVIDER'S CLINICAL JUDGMENT, TO INTERRUPT20
OR DELAY THE PROVISION OF CARE TO THE COVERED PERSON IN ORDER TO21
OBTAIN PRIOR AUTHORIZATION FOR THE ADDITIONAL OR RELATED22
HEALTH-CARE PROCEDURE WOULD NOT BE MEDICALLY ADVISABLE ;23
(B) T
HE ADDITIONAL OR RELATED HEALTH -CARE PROCEDURE IS A24
COVERED BENEFIT UNDER THE COVERED PERSON 'S HEALTH BENEFIT PLAN;25
(C) T
HE ADDITIONAL OR RELATED HEALTH -CARE PROCEDURE IS26
NOT EXPERIMENTAL OR INVESTIGATIONAL ;27
1149
-13- (D) AFTER COMPLETING THE ADDITIONAL OR RELATED1
HEALTH-CARE PROCEDURE AND BEFORE SUBMITTING A CLAIM FOR2
PAYMENT, THE PROVIDER NOTIFIES THE CARRIER OR ORGANIZATION THAT3
THE PROVIDER PERFORMED THE ADDITIONAL OR RELATED HEALTH -CARE4
PROCEDURE AND INCLUDES IN THE NOTICE THE INFORMATION REQUIRED5
UNDER THE CARRIER 'S OR ORGANIZATION 'S CURRENT PRIOR6
AUTHORIZATION REQUIREMENTS POSTED IN ACCORDANCE WITH7
SUBSECTION (2)(a)(I) OF THIS SECTION; AND8
(E) T
HE PROVIDER IS COMPLIANT WITH THE CARRIER 'S OR9
ORGANIZATION'S POST-SERVICE CLAIMS PROCESS, INCLUDING SUBMISSION10
OF THE CLAIM WITHIN THE CARRIER 'S OR ORGANIZATION'S REQUIRED11
TIMELINE FOR CLAIMS SUBMISSIONS.12
(II) W
HEN A PROVIDER PROVIDES AN ADDITIONAL OR A RELATED13
HEALTH-CARE PROCEDURE AS DESCRIBED IN THIS SUBSECTION
(4)(c), THE14
CARRIER OR ORGANIZATION SHALL NOT DENY THE CLAIM FOR THE INITIAL15
SURGICAL PROCEDURE FOR WHICH THE CARRIER OR ORGANIZATION16
APPROVED A PRIOR AUTHORIZATION REQUEST ON THE BASIS THAT THE17
PROVIDER PROVIDED THE ADDITIONAL OR RELATED HEALTH -CARE18
PROCEDURE.19
(5) Duration of approval. (a) Upon approval by the carrier or20
organization, a prior authorization is valid for at least one hundred eighty21
days CALENDAR YEAR after the date of approval and continues for the22
duration of the authorized course of treatment. Except as provided in23
subsection (5)(b) of this section, once approved, a carrier or
AN24
organization shall not retroactively deny the prior authorization request25
for a health-care service.26
(6) Rules - enforcement. (a) The commissioner may adopt rules27
1149
-14- as necessary to implement this section.1
(b) T
HE COMMISSIONER MAY ENFORCE THE REQUIREMENTS OF THIS2
SECTION AND IMPOSE A PENALTY OR OTHER REMEDY AGAINST A PERSON3
THAT VIOLATES THIS SECTION.4
(7) Definitions. As used in this section:5
(e) "Private utilization review organization" or "organization" has
6
the same meaning as set forth MEANS A PRIVATE UTILIZATION REVIEW7
ORGANIZATION, AS DEFINED in section 10-16-112 (1)(a), THAT HAS A8
CONTRACT WITH AND PERFORMS PRIOR AUTHORIZATION ON BEHALF OF A9
CARRIER.10
11
SECTION 3. In Colorado Revised Statutes, 10-16-124.5, amend12
(2)(a)(II)(A), (2)(c)(II)(A), (3)(a) introductory portion, (3)(a)(I),13
(3)(a)(VI), (3)(b) introductory portion, (5), and (6); repeal (3)(a)(II) and14
(4); and add (3.3), (3.5), (5.5), and (6.5) as follows:15
10-16-124.5. Prior authorization form - drug benefits - rules16
of commissioner - definitions - repeal. (2) (a) Except as provided in17
subsection (2)(b) or (2)(c) of this section, a prior authorization request is18
deemed granted if a carrier or pharmacy benefit management firm fails to:19
(II) For prior authorization requests submitted electronically:20
(A) Notify the prescribing provider, within two business days after21
receipt of the request, that the request is approved, denied, or incomplete,22
and if incomplete, indicate the specific additional information, consistent23
with criteria posted pursuant to subparagraph (II) of paragraph (a) of24
subsection (3) SUBSECTION (3.5)(a) of this section, that is required to25
process the request; or26
(c) For nonurgent prior authorization requests related to a covered27
1149
-15- person's HIV prescription drug coverage, the prior authorization request1
is deemed granted if a carrier or pharmacy benefit management firm fails2
to:3
(II) For prior authorization requests submitted electronically:4
(A) Notify the prescribing provider within one business day after5
receipt of the request that the request is approved, denied, or incomplete,6
and if incomplete, indicate the specific additional information, consistent7
with criteria posted pursuant to subsection (3)(a)(II) SUBSECTION (3.5)(a)8
of this section, that is required to process the request; or9
(3) (a) On or before July 31, 2014, The commissioner shall10
develop, by rule, a uniform prior authorization process that:11
(I) Is made available electronically by the carrier or pharmacy12
benefit management firm, but that does not require the prescribing13
provider to submit a prior authorization request electronically, AND14
SATISFIES THE REQUIREMENTS OF SUBSECTION (3.3) OF THIS SECTION;15
(II) Requires each carrier and pharmacy benefit management firm16
to make the following available and accessible in a centralized location17
on its website:18
(A) Its prior authorization requirements and restrictions, including19
a list of drugs that require prior authorization;20
(B) Written clinical criteria that are easily understandable to the21
prescribing provider and that include the clinical criteria for22
reauthorization of a previously approved drug after the prior authorization23
period has expired; and24
(C) The standard form for submitting requests;25
(VI) Requires carriers and pharmacy benefit management firms,26
when notifying a prescribing provider of its decision to deny a prior27
1149
-16- authorization request, to include THE INFORMATION REQUIRED BY SECTION1
10-16-112.5 (3)(c)(II) AND a notice that the covered person has a right to2
appeal the adverse determination pursuant to sections 10-16-113 and3
10-16-113.5.4
(b) In developing the uniform prior authorization process, the5
commissioner shall take into consideration the recommendations, if any,6
of the work group established pursuant to subsection (4) of this section7
and the following:8
(3.3) STARTING JANUARY 1, 2027, IF A PROVIDER SUBMITS A PRIOR9
AUTHORIZATION REQUEST TO A CARRIER OR PBM THROUGH A SECURE10
ELECTRONIC TRANSMISSION SYSTEM THE CARRIER OR PBM USES THAT11
COMPLIES WITH THE MOST RECENT VERSION OF THE NATIONAL COUNCIL12
FOR PRESCRIPTION DRUG PROGRAMS SCRIPT STANDARD, OR ITS13
SUCCESSOR STANDARD, AND 21 CFR 1311, THE CARRIER OR PBM SHALL14
ACCEPT AND RESPOND TO THE REQUEST THOUGH THE SECURE ELECTRONIC15
TRANSMISSION SYSTEM.16
(3.5) (a) O
N AND AFTER JANUARY 1, 2026, A CARRIER SHALL POST17
ON THE CARRIER'S PUBLIC-FACING WEBSITE, IN A READILY ACCESSIBLE,18
STANDARDIZED, SEARCHABLE FORMAT , PRIOR AUTHORIZATION19
REQUIREMENTS AS APPLICABLE TO THE PRESCRIPTION DRUG FORMULARY20
FOR EACH HEALTH BENEFIT PLAN THE CARRIER OFFERS , INCLUDING THE21
FOLLOWING INFORMATION :22 (I) THE CARRIER'S PRIOR AUTHORIZATION REQUIREMENTS AND23
RESTRICTIONS, INCLUDING A LIST OF DRUGS THAT REQUIRE PRIOR24
AUTHORIZATION;25
(II) WRITTEN CLINICAL CRITERIA THAT ARE EASILY26
UNDERSTANDABLE TO THE PRESCRIBING PROVIDER AND THAT INCLUDE THE27
1149
-17- CLINICAL CRITERIA FOR REAUTHORIZATION OF A PREVIOUSLY APPROVED1
DRUG AFTER THE PRIOR AUTHORIZATION PERIOD HAS EXPIRED ;2
(III) THE STANDARD FORM FOR SUBMITTING PRIOR AUTHORIZATION3
REQUESTS;4
(IV) THE HEALTH BENEFIT PLAN TO WHICH THE FORMULARY5
APPLIES;6
(V) EACH PRESCRIPTION DRUG THAT IS COVERED UNDER THE7
HEALTH BENEFIT PLAN, INCLUDING BOTH GENERIC AND BRAND -NAME8
VERSIONS OF A PRESCRIPTION DRUG;9
(VI) ANY PRESCRIPTION DRUGS ON THE FORMULARY THAT ARE10
PREFERRED OVER OTHER PRESCRIPTION DRUGS OR ANY ALTERNATIVE11
PRESCRIPTION DRUGS THAT DO NOT REQUIRE PRIOR AUTHORIZATION ;12
(VII) ANY EXCLUSIONS FROM OR RESTRICTIONS ON COVERAGE ,13
INCLUDING:14
(A) A
NY TIERING STRUCTURE, INCLUDING COPAYMENT AND15
COINSURANCE REQUIREMENTS ;16
(B) P
RIOR AUTHORIZATION, STEP THERAPY, AND OTHER17
UTILIZATION MANAGEMENT CONTROLS ;18
(C) Q
UANTITY LIMITS; AND19
(D) W
HETHER ACCESS IS DEPENDENT UPON THE LOCATION WHERE20
A PRESCRIPTION DRUG IS OBTAINED OR ADMINISTERED ; AND21
(VIII) THE APPEAL PROCESS FOR A DENIAL OF COVERAGE OR22
ADVERSE DETERMINATION FOR AN ITEM OR SERVICE FOR A PRESCRIPTION23
DRUG.24
(b) T
HE COMMISSIONER SHALL ADOPT RULES AS NECESSARY TO25
IMPLEMENT THIS SUBSECTION (3.5).26
(4) (a) Within thirty days after May 15, 2013, the commissioner
27
1149
-18- shall establish a work group comprised of representatives of:1
(I) The department of regulatory agencies;2
(II) Local and national carriers;3
(III) Captive and noncaptive pharmacy benefit management firms;4
(IV) Providers, including hospitals, physicians, advanced practice5
registered nurses with prescriptive authority, and pharmacists;6
(V) Drug manufacturers;7
(VI) Medical practice managers;8
(VII) Consumers; and9
(VIII) Other stakeholders deemed appropriate by the10
commissioner.11
(b) The work group shall assist the commissioner in developing12
the prior authorization process and shall make recommendations to the13
commissioner on the items set forth in paragraph (b) of subsection (3) of14
this section. The work group shall report its recommendations to the15
commissioner no later than six months after the commissioner appoints16
the work group members. Regardless of whether the work group submits17
recommendations to the commissioner, the commissioner shall not delay18
or extend the deadline for the adoption of rules creating the prior19
authorization process as specified in paragraph (a) of subsection (3) of20
this section.21
(5) (a) Notwithstanding any other provision of law, on and after22
January 1, 2015 AND EXCEPT AS PROVIDED IN SUBSECTIONS (5)(b) AND23
(5.5)
OF THIS SECTION, every prescribing provider shall use the prior24
authorization process developed pursuant to subsection (3) of this section25
to request prior authorization for coverage of drug benefits, and every26
carrier and pharmacy benefit management firm shall use that process for27
1149
-19- prior authorization for drug benefits.1
(b) (I) A
CARRIER OR PBM THAT PROVIDES DRUG BENEFITS UNDER2
A HEALTH BENEFIT PLAN SHALL NOT IMPOSE PRIOR AUTHORIZATION3
REQUIREMENTS UNDER THE HEALTH BENEFIT PLAN
MORE THAN ONCE4
EVERY THREE YEARS FOR A DRUG THAT IS APPROVED BY THE FDA AND5
THAT IS A CHRONIC MAINTENANCE DRUG IF THE CARRIER OR PBM HAS6
PREVIOUSLY APPROVED A PRIOR AUTHORIZATION FOR THE COVERED7
PERSON FOR USE OF THE CHRONIC MAINTENANCE DRUG .8
(II) THIS SUBSECTION (5)(b) DOES NOT APPLY IF:9
(A) THERE IS EVIDENCE THAT THE AUTHORIZATION WAS OBTAINED10
FROM THE CARRIER OR PBM BASED ON FRAUD OR MISREPRESENTATION ;11
(B) FINAL ACTION BY THE FDA OR OTHER REGULATORY AGENCIES,12
OR THE MANUFACTURER, REMOVES THE CHRONIC MAINTENANCE DRUG13
FROM THE MARKET, LIMITS ITS USE IN A MANNER THAT AFFECTS THE14
AUTHORIZATION, OR COMMUNICATES A PATIENT SAFETY ISSUE THAT15
WOULD AFFECT THE AUTHORIZATION ALONE OR IN COMBINATION WITH16
OTHER AUTHORIZATIONS;17
(C) A GENERIC EQUIVALENT OR DRUG THAT IS BIOSIMILAR, AS18
DEFINED IN 42 U.S.C. SEC. 262 (i)(2), TO THE PRESCRIBED CHRONIC19
MAINTENANCE DRUG IS ADDED TO THE CARRIER'S OR PBM'S DRUG20
FORMULARY; OR21
(D) THE WHOLESALE ACQUISITION COST OF THE CHRONIC22
MAINTENANCE DRUG EXCEEDS A DOLLAR AMOUNT AS ESTABLISHED BY23
THE COMMISSIONER BY RULE, WHICH AMOUNT MUST BE NO LESS THAN24
THIRTY THOUSAND DOLLARS FOR A TWELVE-MONTH SUPPLY OR FOR A25
COURSE OF TREATMENT THAT IS LESS THAN TWELVE MONTHS IN26
DURATION.27
1149
-20- (III) NOTHING IN THIS SUBSECTION (5)(b) REQUIRES A CARRIER OR1
PBM TO PAY FOR A BENEFIT:2
(A) THAT IS NOT A COVERED BENEFIT UNDER THE HEALTH BENEFIT3
PLAN; OR4
(B) IF THE PATIENT IS NO LONGER A COVERED PERSON UNDER THE5
HEALTH BENEFIT PLAN ON THE DATE THE CHRONIC MAINTENANCE DRUG6
WAS PRESCRIBED, DISPENSED, ADMINISTERED, OR DELIVERED.7
(IV) AS USED IN THIS SUBSECTION (5)(b), "CHRONIC MAINTENANCE8
DRUG" HAS THE MEANING SET FORTH IN SECTION 12-280-103 (9.5).9
10
(5.5) (a) N
O LATER THAN JANUARY 1, 2026, A CARRIER OR PBM11
SHALL ADOPT A PROGRAM, DEVELOPED IN CONSULTATION WITH PROVIDERS12
PARTICIPATING WITH THE CARRIER , TO ELIMINATE OR SUBSTANTIALLY13
MODIFY PRIOR AUTHORIZATION REQUIREMENTS IN A MANNER THAT14
REMOVES THE ADMINISTRATIVE BURDEN FOR QUALIFIED PROVIDERS , AS15
DEFINED UNDER THE PROGRAM , AND THEIR PATIENTS FOR CERTAIN16
PRESCRIPTION DRUGS AND RELATED DRUG BENEFITS BASED ON ANY OF THE17
FOLLOWING:18
(I) T
HE PERFORMANCE OF PROVIDERS WITH RESPECT TO19
ADHERENCE TO NATIONALLY RECOGNIZED , EVIDENCE-BASED MEDICAL20
GUIDELINES, APPROPRIATENESS, EFFICIENCY, AND OTHER QUALITY21
CRITERIA; AND22
(II) P
ROVIDER SPECIALTY, EXPERIENCE, OR OTHER OBJECTIVE23
FACTORS; EXCEPT THAT ELIGIBILITY FOR THE PROGRAM MUST NOT BE24
LIMITED BY PROVIDER SPECIALTY.25
(b) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF26
THIS SECTION:27
1149
-21- (I) MUST NOT REQUIRE QUALIFIED PROVIDERS TO REQUEST1
PARTICIPATION IN THE PROGRAM; AND2
(II) M
AY INCLUDE LIMITING THE USE OF PRIOR AUTHORIZATION TO3
PROVIDERS WHOSE PRESCRIBING OR ORDERING PATTERNS DIFFER4
SIGNIFICANTLY FROM THE PATTERNS OF THEIR PEERS AFTER ADJUSTING5
FOR PATIENT MIX AND OTHER RELEVANT FACTORS AND IN ORDER TO6
PRESENT THOSE PROVIDERS WITH OPPORTUNITIES FOR IMPROVEMENT IN7
ADHERENCE TO THE CARRIER'S OR ORGANIZATION'S PRIOR AUTHORIZATION8
REQUIREMENTS.9
(c) A
T LEAST ANNUALLY, A CARRIER OR PBM SHALL:10
(I) R
EEXAMINE A PROVIDER 'S PRESCRIBING OR ORDERING11
PATTERNS;12
(II) R
EEVALUATE THE PROVIDER'S STATUS FOR EXEMPTION FROM13
PRIOR AUTHORIZATION REQUIREMENTS OR FOR INCLUSION IN THE14
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF THIS15
SECTION; AND16
(III) N
OTIFY THE PROVIDER OF THE PROVIDER 'S STATUS FOR17
EXEMPTION OR INCLUSION IN THE PROGRAM .18
(d) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF19
THIS SECTION MUST INCLUDE PROCEDURES FOR A PROVIDER TO REQUEST :20
(I) AN EXPEDITED, INFORMAL RESOLUTION OF A CARRIER 'S OR21
PBM'
S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE PROGRAM ;22
AND23 (II) IF THE MATTER IS NOT RESOLVED THROUGH INFORMAL24
RESOLUTION, BINDING ARBITRATION AS SPECIFIED IN SUBSECTION (5.5)(e)25
OF THIS SECTION.26
(e) IF A PROVIDER REQUESTS BINDING ARBITRATION PURSUANT TO27
1149
-22- THE PROCEDURES A CARRIER OR A PBM DEVELOPS UNDER SUBSECTION1
(5.5)(d)(II) OF THIS SECTION, THE FOLLOWING PROVISIONS GOVERN THE2
ARBITRATION PROCEDURE:3
(I) THE PROVIDER AND CARRIER OR PBM SHALL JOINTLY SELECT4
AN ARBITRATOR FROM THE LIST OF ARBITRATORS APPROVED PURSUANT TO5
SECTION 10-16-704 (15)(b). NEITHER THE PROVIDER NOR THE CARRIER OR6
PBM IS REQUIRED TO NOTIFY THE DIVISION OF THE ARBITRATION OR OF7
THE SELECTED ARBITRATOR.8
(II) THE SELECTED ARBITRATOR SHALL DETERMINE THE9
PROVIDER'S ELIGIBILITY TO PARTICIPATE IN THE CARRIER'S OR PBM'S10
PROGRAM BASED ON THE PROGRAM CRITERIA DEVELOPED PURSUANT TO11
SUBSECTION (5.5)(a) OF THIS SECTION;12
(III) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR13
ACCEPTS THE MATTER, THE PROVIDER AND THE CARRIER OR PBM SHALL14
SUBMIT TO THE ARBITRATOR WRITTEN MATERIALS IN SUPPORT OF THEIR15
RESPECTIVE POSITIONS;16
(IV) THE ARBITRATOR MAY RENDER A DECISION BASED ON THE17
WRITTEN MATERIALS SUBMITTED PURSUANT TO SUBSECTION (5.5)(e)(III)18
OF THIS SECTION OR MAY SCHEDULE A HEARING , LASTING NOT LONGER19
THAN ONE DAY, FOR THE PROVIDER AND CARRIER OR PBM TO PRESENT20
EVIDENCE;21
(V) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR22
RECEIVES THE WRITTEN MATERIALS OR, IF A HEARING IS CONDUCTED, THE23
DATE OF THE HEARING , THE ARBITRATOR SHALL ISSUE A WRITTEN24
DECISION STATING WHETHER THE PROVIDER IS ELIGIBLE FOR THE25
PROGRAM; AND26
(VI) IF THE ARBITRATOR OVERTURNS THE CARRIER 'S OR PBM'S27
1149
-23- FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE PROGRAM, THE1
CARRIER OR PBM SHALL PAY THE ARBITRATOR'S FEES AND COSTS, AND IF2
THE ARBITRATOR AFFIRMS THE CARRIER'S OR PBM'S FAILURE OR REFUSAL3
TO INCLUDE THE PROVIDER IN THE PROGRAM, THE PROVIDER SHALL PAY4
THE ARBITRATOR'S FEES AND COSTS.5
(6) Upon approval by the carrier or pharmacy benefit management6
firm, a prior authorization is valid for at least one hundred eighty days7
CALENDAR YEAR after the date of approval. If, as a result of a change to8
the carrier's formulary, the drug for which the carrier or pharmacy benefit9
management firm has provided prior authorization is removed from the10
formulary or moved to a less preferred tier status, the change in the status11
of the previously approved drug does not affect a covered person who12
received prior authorization before the effective date of the change for the13
remainder of the covered person's plan year. Nothing in this subsection14
(6) limits the ability of a carrier or pharmacy benefit management firm,15
in accordance with the terms of the health benefit plan, to substitute a16
generic drug, with the prescribing provider's approval and patient's17
consent, for a previously approved brand-name drug.18
(6.5) T
HE COMMISSIONER MAY ENFORCE THE REQUIREMENTS OF19
THIS SECTION AND IMPOSE A PENALTY OR OTHER REMEDY AGAINST A20
PERSON THAT VIOLATES THIS SECTION.21
22
SECTION 4. Appropriation. (1) For the 2024-25 state fiscal23
year, $36,514 is appropriated to the department of regulatory agencies for24
use by the division of insurance. This appropriation is from the division25
of insurance cash fund created in section 10-1-103 (3)(a)(I), C.R.S. To26
implement this act, the division may use this appropriation as follows:27
1149
-24- (a) $29,332 for personal services, which amount is based on an1
assumption that the division will require an additional 0.4 FTE; and2
(b) $7,182 for operating expenses.3
SECTION 5. Act subject to petition - effective date -4
applicability. (1) This act takes effect at 12:01 a.m. on the day following5
the expiration of the ninety-day period after final adjournment of the6
general assembly; except that, if a referendum petition is filed pursuant7
to section 1 (3) of article V of the state constitution against this act or an8
item, section, or part of this act within such period, then the act, item,9
section, or part will not take effect unless approved by the people at the10
general election to be held in November 2024 and, in such case, will take11
effect on the date of the official declaration of the vote thereon by the12
governor.13
(2) This act applies to conduct occurring on or after January 1,14
2026.15
1149
-25-