Colorado 2024 Regular Session

Colorado House Bill HB1149 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
	1	+	Second Regular Session
	2	+	Seventy-fourth General Assembly
	3	+	STATE OF COLORADO
	4	+	REREVISED
	5	+	This Version Includes All Amendments
	6	+	Adopted in the Second House
	7	+	LLS NO. 24-0202.01 Christy Chase x2008
1	8		HOUSE BILL 24-1149
2		-	BY REPRESENTATIVE(S) Bird and Frizell, Amabile, Armagost, Bacon,
3		-	Boesenecker, Bradfield, Clifford, deGruy Kennedy, Duran, English,
4		-	Froelich, Garcia, Hamrick, Hartsook, Hernandez, Jodeh, Kipp, Lieder,
5		-	Lindstedt, Mabrey, McLachlan, Ortiz, Rutinel, Sirota, Snyder, Soper,
6		-	Taggart, Titone, Valdez, Velasco, Weinberg, Willford, Wilson, Young,
7		-	Brown, Catlin, Lindsay, Marshall, Mauro, McCormick, Parenti, Weissman,
8		-	McCluskie;
9		-	also SENATOR(S) Roberts and Kirkmeyer, Ginal, Baisley, Bridges,
10		-	Buckner, Coleman, Cutter, Gonzales, Hansen, Hinrichsen, Kolker, Liston,
11		-	Marchman, Michaelson Jenet, Mullica, Pelton R., Rich, Van Winkle, Will,
12		-	Winter F., Zenzinger.
	9	+	House Committees Senate Committees
	10	+	Health & Human Services Health & Human Services
	11	+	Appropriations Appropriations
	12	+	A BILL FOR AN ACT
13	13		C
14		-	ONCERNING MODIFICATIONS TO REQUIREMENTS FOR PRIOR AUTHORIZATION
15		-	OF BENEFITS UNDER HEALTH BENEFIT PLANS
16		-	, AND, IN CONNECTION
17		-	THEREWITH
18		-	, MAKING AN APPROPRIATION.
19		-	Be it enacted by the General Assembly of the State of Colorado:
20		-	SECTION 1. Legislative declaration. (1) The general assembly
21		-	finds and declares that:
22		-	(a) Timely access to necessary health care is of vital importance to
23		-	NOTE: This bill has been prepared for the signatures of the appropriate legislative
24		-	officers and the Governor. To determine whether the Governor has signed the bill
25		-	or taken other action on it, please consult the legislative status sheet, the legislative
26		-	history, or the Session Laws.
27		-	________
28		-	Capital letters or bold & italic numbers indicate new material added to existing law; dashes
29		-	through words or numbers indicate deletions from existing law and such material is not part of
30		-	the act. Coloradans;
31		-	(b) The provider-patient relationship is paramount and should not
32		-	be subject to intrusion by a third party;
33		-	(c) Coloradans and their health-care providers deserve easy access
34		-	to information regarding health insurance benefits so that, together, they can
35		-	determine the proper course of treatment;
36		-	(d) Utilization management processes, such as prior authorization,
37		-	delay care, which, according to thirty-four percent of physicians surveyed
38		-	nationally, leads to serious adverse events for their patients, including
39		-	hospitalization, permanent disability, or even death;
40		-	(e) These outcomes due to delays in timely accessing services and
41		-	prescriptions are known to disproportionately impact historically
42		-	marginalized populations, such as Black and Hispanic patients, furthering
43		-	health disparities in the state;
44		-	(f) Surveys have found that over sixty percent of physicians also
45		-	report that it is difficult to determine whether a prescription medication or
46		-	medical service requires prior authorization, adding burdensome
47		-	administrative steps for health-care providers and patients to understand
48		-	requirements for accessing necessary medical services or prescriptions; and
49		-	(g) Health systems spend an average of twenty dollars, for a primary
50		-	care visit, to two hundred fifteen dollars, for an inpatient surgical procedure,
51		-	on administrative tasks to navigate insurer utilization management
52		-	processes like processing prior authorization requests.
53		-	(2) Therefore, it is the intent of the general assembly, by establishing
54		-	transparent prescription formularies and enabling access to prior
55		-	authorization requirements at the point of care delivery; requiring posting
56		-	of data on prior authorization practices; and requiring carriers, private
57		-	utilization review organizations, and pharmacy benefit managers to adopt
58		-	a program that streamlines the administrative process for qualifying
59		-	health-care providers who satisfy certain objective criteria regarding quality
60		-	and appropriateness of care and specialty area and experience, to:
61		-	(a) Ensure Coloradans have equitable access to medically necessary
62		-	PAGE 2-HOUSE BILL 24-1149 care;
63		-	(b) Reduce administrative burdens and costs borne by health-care
64		-	providers; and
65		-	(c) Reduce overall costs to the health-care system.
66		-	SECTION 2. In Colorado Revised Statutes, 10-16-112.5, amend
67		-	(2)(a), (2)(c), (3)(a)(I), (3)(c)(II), (4)(b), (5)(a), (6), and (7)(e); and add
68		-	(3)(c)(III), (3.5), and (4)(c) as follows:
69		-	10-16-112.5. Prior authorization for health-care services -
70		-	disclosures and notice - determination deadlines - criteria - limits and
71		-	exceptions - definitions - rules - enforcement. (2) Disclosure of
72		-	requirements - notice of changes. (a) (I) A carrier shall make
73		-	POST
74		-	current prior authorization requirements and restrictions, including written,
75		-	clinical criteria, readily accessible on the carrier's PUBLIC-FACING website
76		-	IN A READILY ACCESSIBLE, STANDARDIZED, SEARCHABLE FORMAT. The prior
77		-	authorization requirements must be described in detail and in clear and
78		-	easily understandable language.
79		-	(II) If a carrier contracts with a private utilization review
80		-	organization to perform prior authorization for health-care services, the
81		-	organization shall provide its prior authorization requirements and
	14	+	ONCERNING MODIFICATIONS TO REQUIREMENTS FOR PRIOR101
	15	+	AUTHORIZATION OF BENEFITS UNDER HEALTH BENEFIT
	16	+	PLANS,102
	17	+	AND, IN CONNECTION THEREWITH, MAKING AN APPROPRIATION.103
	18	+	Bill Summary
	19	+	(Note: This summary applies to this bill as introduced and does
	20	+	not reflect any amendments that may be subsequently adopted. If this bill
	21	+	passes third reading in the house of introduction, a bill summary that
	22	+	applies to the reengrossed version of this bill will be available at
	23	+	http://leg.colorado.gov
	24	+	.)
	25	+	With regard to prior authorization requirements imposed by
	26	+	carriers, private utilization review organizations (organizations), and
	27	+	pharmacy benefit managers (PBMs) for certain health-care services and
	28	+	prescription drug benefits covered under a health benefit plan, the bill
	29	+	requires carriers, organizations, and PBMs, as applicable, to adopt a
	30	+	SENATE
	31	+	3rd Reading Unamended
	32	+	April 25, 2024
	33	+	SENATE
	34	+	2nd Reading Unamended
	35	+	April 24, 2024
	36	+	HOUSE
	37	+	3rd Reading Unamended
	38	+	March 11, 2024
	39	+	HOUSE
	40	+	Amended 2nd Reading
	41	+	March 8, 2024
	42	+	HOUSE SPONSORSHIP
	43	+	Bird and Frizell, Amabile, Armagost, Bacon, Boesenecker, Bradfield, Clifford, deGruy
	44	+	Kennedy, Duran, English, Froelich, Garcia, Hamrick, Hartsook, Hernandez, Jodeh, Kipp,
	45	+	Lieder, Lindstedt, Mabrey, McLachlan, Ortiz, Rutinel, Sirota, Snyder, Soper, Taggart, Titone,
	46	+	Valdez, Velasco, Weinberg, Willford, Wilson, Young, Brown, Catlin, Lindsay, Marshall,
	47	+	Mauro, McCluskie, McCormick, Parenti, Weissman
	48	+	SENATE SPONSORSHIP
	49	+	Roberts and Kirkmeyer, Ginal, Baisley, Bridges, Buckner, Coleman, Cutter, Gonzales,
	50	+	Hansen, Hinrichsen, Kolker, Liston, Marchman, Michaelson Jenet, Mullica, Pelton R., Rich,
	51	+	Van Winkle, Will, Winter F., Zenzinger
	52	+	Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.
	53	+	Capital letters or bold & italic numbers indicate new material to be added to existing law.
	54	+	Dashes through the words or numbers indicate deletions from existing law. program, in consultation with participating providers, to eliminate or
	55	+	substantially modify prior authorization requirements in a manner that
	56	+	removes administrative burdens on qualified providers and their patients
	57	+	with regard to certain health-care services, prescription drugs, or related
	58	+	benefits based on specified criteria. Additionally, a carrier or organization
	59	+	is prohibited from denying a claim for a health-care procedure a provider
	60	+	provides, in addition or related to an approved surgical procedure, under
	61	+	specified circumstances or from denying an initially approved surgical
	62	+	procedure on the basis that the provider provided an additional or a
	63	+	related health-care procedure.
	64	+	The bill extends the duration of an approved prior authorization for
	65	+	a health-care service or prescription drug benefit from 180 days to a
	66	+	calendar year.
	67	+	Carriers are required to post, on their public-facing websites,
	68	+	specified information regarding:
	69	+	! The number of prior authorization requests that are
	70	+	approved, denied, and appealed;
	71	+	! The number of prior authorization exemptions or
	72	+	alternatives to prior authorization requirements provided
	73	+	pursuant to a program developed and offered by the carrier,
	74	+	an organization, or a PBM; and
	75	+	! The prior authorization requirements as applied to
	76	+	prescription drug formularies for each health benefit plan
	77	+	the carrier or PBM offers.
	78	+	The bill applies to conduct occurring on or after January 1, 2026.
	79	+	Be it enacted by the General Assembly of the State of Colorado:1
	80	+	SECTION 1. Legislative declaration. (1) The general assembly2
	81	+	finds and declares that:3
	82	+	(a) Timely access to necessary health care is of vital importance4
	83	+	to Coloradans;5
	84	+	(b) The provider-patient relationship is paramount and should not6
	85	+	be subject to intrusion by a third party;7
	86	+	(c) Coloradans and their health-care providers deserve easy access8
	87	+	to information regarding health insurance benefits so that, together, they9
	88	+	can determine the proper course of treatment;10
	89	+	(d) Utilization management processes, such as prior authorization,11
	90	+	1149-2- delay care, which, according to thirty-four percent of physicians surveyed1
	91	+	nationally, leads to serious adverse events for their patients, including2
	92	+	hospitalization, permanent disability, or even death;3
	93	+	(e) These outcomes due to delays in timely accessing services and4
	94	+	prescriptions are known to disproportionately impact historically5
	95	+	marginalized populations, such as Black and Hispanic patients, furthering6
	96	+	health disparities in the state;7
	97	+	(f) Surveys have found that over sixty percent of physicians also8
	98	+	report that it is difficult to determine whether a prescription medication9
	99	+	or medical service requires prior authorization, adding burdensome10
	100	+	administrative steps for health-care providers and patients to understand11
	101	+	requirements for accessing necessary medical services or prescriptions;12
	102	+	and13
	103	+	(g) Health systems spend an average of twenty dollars, for a14
	104	+	primary care visit, to two hundred fifteen dollars, for an inpatient surgical15
	105	+	procedure, on administrative tasks to navigate insurer utilization16
	106	+	management processes like processing prior authorization requests.17
	107	+	(2) Therefore, it is the intent of the general assembly, by18
	108	+	establishing transparent prescription formularies and enabling access to19
	109	+	prior authorization requirements at the point of care delivery; requiring20
	110	+	posting of data on prior authorization practices; and requiring carriers,21
	111	+	private utilization review organizations, and pharmacy benefit managers22
	112	+	to adopt a program that streamlines the administrative process for23
	113	+	qualifying health-care providers who satisfy certain objective criteria24
	114	+	regarding quality and appropriateness of care and specialty area and25
	115	+	experience, to:26
	116	+	(a) Ensure Coloradans have equitable access to medically27
	117	+	1149
	118	+	-3- necessary care;1
	119	+	(b) Reduce administrative burdens and costs borne by health-care2
	120	+	providers; and3
	121	+	(c) Reduce overall costs to the health-care system.4
	122	+	SECTION 2. In Colorado Revised Statutes, 10-16-112.5, amend5
	123	+	(2)(a), (2)(c), (3)(a)(I), (3)(c)(II), (4)(b), (5)(a), (6), and (7)(e); and add6
	124	+	(3)(c)(III), (3.5), and (4)(c) as follows:7
	125	+	10-16-112.5. Prior authorization for health-care services -8
	126	+	disclosures and notice - determination deadlines - criteria - limits and9
	127	+	exceptions - definitions - rules - enforcement. (2) Disclosure of10
	128	+	requirements - notice of changes. (a) (I) A carrier shall make POST11
	129	+	current prior authorization requirements and restrictions, including12
	130	+	written, clinical criteria, readily accessible on the carrier's PUBLIC-FACING13
	131	+	website
	132	+	IN A READILY ACCESSIBLE, STANDARDIZED, SEARCHABLE FORMAT.14
	133	+	The prior authorization requirements must be described in detail and in15
	134	+	clear and easily understandable language.16
	135	+	(II) If a carrier contracts with a private utilization review17
	136	+	organization to perform prior authorization for health-care services, the18
	137	+	organization shall provide its prior authorization requirements and19
82	138		restrictions, as required by this subsection (2), to the carrier with whom
83		-	WHICH the organization contracted, and that carrier shall post the
84		-	organization's prior authorization requirements and restrictions on its
85		-	PUBLIC-FACING website IN THE MANNER REQUIRED BY SUBSECTION (2)(a)(I)
86		-	OF THIS SECTION.
87		-	(III) When posting prior authorization requirements and restrictionspursuant to this subsection (2)(a) or subsection (2)(b) of this section, a
88		-	carrier is neither required to post nor prohibited from posting the prior
89		-	authorization requirements and restrictions on a public-facing portion of its
90		-	website.
91		-	(c) (I) A carrier shall post, on a public-facing portion of its website,
92		-	data regarding approvals and denials of prior authorization requests,
93		-	including requests for drug benefits pursuant to section 10-16-124.5, in a
94		-	readily accessible,
95		-	STANDARDIZED, SEARCHABLE format and that include the
96		-	PAGE 3-HOUSE BILL 24-1149 following: categories, in the aggregate:
97		-	(A) Provider specialty THE TOTAL NUMBER OF PRIOR
98		-	AUTHORIZATION REQUESTS RECEIVED IN THE IMMEDIATELY PRECEDING
99		-	CALENDAR YEAR IN EACH OF THE FOLLOWING CATEGORIES OF SERVICES
100		-	:
	139	+	20
	140	+	WHICH the organization contracted, and that carrier shall post the21
	141	+	organization's prior authorization requirements and restrictions on its22
	142	+	PUBLIC-FACING website IN THE MANNER REQUIRED BY SUBSECTION23
	143	+	(2)(a)(I)
	144	+	OF THIS SECTION.24
	145	+	(III) When posting prior authorization requirements and
	146	+	25
	147	+	restrictions pursuant to this subsection (2)(a) or subsection (2)(b) of this26
	148	+	section, a carrier is neither required to post nor prohibited from posting27
	149	+	1149
	150	+	-4- the prior authorization requirements and restrictions on a public-facing1
	151	+	portion of its website.2
	152	+	(c) (I) A carrier shall post, on a public-facing portion of its3
	153	+	website, data regarding approvals and denials of prior authorization4
	154	+	requests, including requests for drug benefits pursuant to section5
	155	+	10-16-124.5, in a readily accessible,
	156	+	STANDARDIZED, SEARCHABLE format6
	157	+	and that include the following: categories, in the aggregate:
	158	+	7
	159	+	(A) Provider specialty THE TOTAL NUMBER OF PRIOR8
	160	+	AUTHORIZATION REQUESTS RECEIVED IN THE IMMEDIATELY PRECEDING9
	161	+	CALENDAR YEAR IN EACH OF THE FOLLOWING CATEGORIES OF SERVICES :10
101	162		M
102		-	EDICAL PROCEDURES; DIAGNOSTIC TESTS AND DIAGNOSTIC IMAGES ;
103		-	PRESCRIPTION DRUGS; AND ALL OTHER CATEGORIES OF HEALTH -CARE
104		-	SERVICES OR DRUG BENEFITS FOR WHICH A PRIOR AUTHORIZATION REQUEST
105		-	WAS RECEIVED
106		-	;
	163	+	EDICAL PROCEDURES; DIAGNOSTIC TESTS AND DIAGNOSTIC IMAGES ;11
	164	+	PRESCRIPTION DRUGS; AND ALL OTHER CATEGORIES OF HEALTH -CARE12
	165	+	SERVICES OR DRUG BENEFITS FOR WHICH A PRIOR AUTHORIZATION13
	166	+	REQUEST WAS RECEIVED;14
107	167		(B) Medication or diagnostic test or procedure
108		-	THE TOTAL NUMBER
109		-	OF PRIOR AUTHORIZATION REQUESTS THAT WERE APPROVED IN EACH OF THE
110		-	CATEGORIES SPECIFIED IN SUBSECTION
111		-	(2)(c)(I)(A) OF THIS SECTION;
112		-	(B.5) T
113		-	HE TOTAL NUMBER OF PRIOR AUTHORIZATION REQUESTS FOR
114		-	WHICH AN ADVERSE DETERMINATION WAS ISSUED AND THE SERVICE WAS
115		-	DENIED IN EACH OF THE CATEGORIES SPECIFIED IN SUBSECTION
	168	+	THE TOTAL15
	169	+	NUMBER OF PRIOR AUTHORIZATION REQUESTS THAT WERE APPROVED IN16
	170	+	EACH OF THE CATEGORIES SPECIFIED IN SUBSECTION (2)(c)(I)(A) OF THIS17
	171	+	SECTION;18
	172	+	(B.5) THE TOTAL NUMBER OF PRIOR AUTHORIZATION REQUESTS19
	173	+	FOR WHICH AN ADVERSE DETERMINATION WAS ISSUED AND THE SERVICE20
	174	+	WAS DENIED IN EACH OF THE CATEGORIES SPECIFIED IN SUBSECTION21
116	175		(2)(c)(I)(A)
117	176		OF THIS SECTION;
	177	+	22
	178	+	(C) THE reason for THE denial IN EACH OF THE CATEGORIES23
	179	+	SPECIFIED IN SUBSECTION (2)(c)(I)(A) OF THIS SECTION, WITH THE DENIAL24
	180	+	REASONS SORTED BY CATEGORIES DEFINED BY RULE ; and25
	181	+	(D) Denials specified under subsection (2)(c)(I)(C) of this section26
	182	+	that are overturned on appeal IN EACH OF THE CATEGORIES SPECIFIED IN27
	183	+	1149
	184	+	-5- SUBSECTION (2)(c)(I)(A) OF THIS SECTION, THE TOTAL NUMBER OF1
	185	+	ADVERSE DETERMINATIONS THAT WERE APPEALED AND WHETHER THE2
	186	+	DETERMINATION WAS UPHELD OR REVERSED ON APPEAL .3
	187	+	(II) An organization
	188	+	OR PBM that provides prior authorization for4
	189	+	a carrier shall provide the data specified in subsection (2)(c)(I) of this5
	190	+	section to the carrier with whom
	191	+	WHICH the organization OR PBM6
	192	+	contracted, and the carrier shall post the organization's
	193	+	OR PBM'S data on7
	194	+	its
	195	+	PUBLIC-FACING website IN THE MANNER REQUIRED BY SUBSECTION8
	196	+	(2)(c)(I)
	197	+	OF THIS SECTION.9
	198	+	(III) Carriers and organizations shall use the data specified in this10
	199	+	subsection (2)(c) to refine and improve their utilization management11
	200	+	programs. C
	201	+	ARRIERS AND ORGANIZATIONS SHALL REVIEW THE LIST OF12
	202	+	MEDICAL PROCEDURES , DIAGNOSTIC TESTS AND DIAGNOSTIC IMAGES ,13
	203	+	PRESCRIPTION DRUGS, AND OTHER HEALTH-CARE SERVICES FOR WHICH THE14
	204	+	CARRIER OR ORGANIZATION REQUIRES PRIOR AUTHORIZATION AT LEAST15
	205	+	ANNUALLY AND SHALL ELIMINATE THE PRIOR AUTHORIZATION16
	206	+	REQUIREMENTS FOR THOSE PROCEDURES , DIAGNOSTIC TESTS AND17
	207	+	DIAGNOSTIC IMAGES, PRESCRIPTION DRUGS, OR OTHER HEALTH-CARE18
	208	+	SERVICES FOR WHICH PRIOR AUTHORIZATION
	209	+	NEITHER PROMOTES19
	210	+	HEALTH-CARE QUALITY OR EQUITY NOR SUBSTANTIALLY REDUCES20
	211	+	HEALTH-CARE SPENDING. EACH CARRIER AND ORGANIZATION SHALL21
	212	+	ANNUALLY ATTEST TO THE COMMISSIONER THAT IT HAS COMPLETED THE22
	213	+	REVIEW REQUIRED BY THIS SUBSECTION (2)(c)(III) AND HAS ELIMINATED23
	214	+	PRIOR AUTHORIZATION REQUIREMENTS CONSISTENT WITH THE24
	215	+	REQUIREMENTS OF THIS SUBSECTION (2)(c)(III).25
	216	+	(IV) A
	217	+	CARRIER SHALL POST, ON A PUBLIC-FACING PORTION OF ITS26
	218	+	WEBSITE, IN A READILY ACCESSIBLE , STANDARDIZED, SEARCHABLE27
	219	+	1149
	220	+	-6- FORMAT, DATA ON THE NUMBER OF EXEMPTIONS FROM PRIOR1
	221	+	AUTHORIZATION REQUIREMENTS OR ALTERNATIVES TO PRIOR2
	222	+	AUTHORIZATION REQUIREMENTS PROVIDED PURSUANT TO A PROGRAM3
	223	+	ADOPTED BY THE CARRIER , ORGANIZATION, OR PBM PURSUANT TO4
	224	+	SUBSECTION (4)(b)(II) OF THIS SECTION OR SECTION 10-16-124.5 (5.5), AS5
	225	+	APPLICABLE. THE CARRIER SHALL INCLUDE THE FOLLOWING DATA :6
	226	+	(A) T
	227	+	HE NUMBER OF PROVIDERS OFFERED AN EXEMPTION OR7
	228	+	ALTERNATIVE PROGRAM , INCLUDING THEIR SPECIALTY AREAS;8
	229	+	(B) T
	230	+	HE NUMBER AND CATEGORIZED TYPES OF EXEMPTIONS OR9
	231	+	ALTERNATIVE PROGRAMS OFFERED TO PROVIDERS ; AND10
118	232		(C) T
119		-	HE reason for THE denial IN EACH OF THE CATEGORIES
120		-	SPECIFIED IN SUBSECTION
121		-	(2)(c)(I)(A) OF THIS SECTION, WITH THE DENIAL
122		-	REASONS SORTED BY CATEGORIES DEFINED BY RULE
123		-	; and
124		-	(D) Denials specified under subsection (2)(c)(I)(C) of this section
125		-	that are overturned on appeal IN EACH OF THE CATEGORIES SPECIFIED IN
126		-	SUBSECTION
127		-	(2)(c)(I)(A) OF THIS SECTION, THE TOTAL NUMBER OF ADVERSE
128		-	DETERMINATIONS THAT WERE APPEALED AND WHETHER THE
129		-	DETERMINATION WAS UPHELD OR REVERSED ON APPEAL
130		-	.
131		-	(II) An organization
132		-	OR PBM that provides prior authorization for
133		-	a carrier shall provide the data specified in subsection (2)(c)(I) of this
134		-	section to the carrier with whom
135		-	WHICH the organization OR PBM
136		-	contracted, and the carrier shall post the organization's
137		-	OR PBM'S data on
138		-	its
139		-	PUBLIC-FACING website IN THE MANNER REQUIRED BY SUBSECTION
140		-	(2)(c)(I) OF THIS SECTION.
141		-	(III) Carriers and organizations shall use the data specified in this
142		-	subsection (2)(c) to refine and improve their utilization management
143		-	programs. C
144		-	ARRIERS AND ORGANIZATIONS SHALL REVIEW THE LIST OF
145		-	MEDICAL PROCEDURES
146		-	, DIAGNOSTIC TESTS AND DIAGNOSTIC IMAGES ,
147		-	PAGE 4-HOUSE BILL 24-1149 PRESCRIPTION DRUGS, AND OTHER HEALTH-CARE SERVICES FOR WHICH THE
148		-	CARRIER OR ORGANIZATION REQUIRES PRIOR AUTHORIZATION AT LEAST
149		-	ANNUALLY AND SHALL ELIMINATE THE PRIOR AUTHORIZATION
150		-	REQUIREMENTS FOR THOSE PROCEDURES
151		-	, DIAGNOSTIC TESTS AND
152		-	DIAGNOSTIC IMAGES
153		-	, PRESCRIPTION DRUGS, OR OTHER HEALTH -CARE
154		-	SERVICES FOR WHICH PRIOR AUTHORIZATION NEITHER PROMOTES
155		-	HEALTH
156		-	-CARE QUALITY OR EQUITY NOR SUBSTANTIALLY REDUCES
157		-	HEALTH
158		-	-CARE SPENDING. EACH CARRIER AND ORGANIZATION SHALL
159		-	ANNUALLY ATTEST TO THE COMMISSIONER THAT IT HAS COMPLETED THE
160		-	REVIEW REQUIRED BY THIS SUBSECTION
161		-	(2)(c)(III) AND HAS ELIMINATED
162		-	PRIOR AUTHORIZATION REQUIREMENTS CONSISTENT WITH THE
163		-	REQUIREMENTS OF THIS SUBSECTION
164		-	(2)(c)(III).
165		-	(IV) A
166		-	CARRIER SHALL POST, ON A PUBLIC-FACING PORTION OF ITS
167		-	WEBSITE
168		-	, IN A READILY ACCESSIBLE, STANDARDIZED, SEARCHABLE FORMAT,
169		-	DATA ON THE NUMBER OF EXEMPTIONS FROM PRIOR AUTHORIZATION
170		-	REQUIREMENTS OR ALTERNATIVES TO PRIOR AUTHORIZATION REQUIREMENTS
171		-	PROVIDED PURSUANT TO A PROGRAM ADOPTED BY THE CARRIER
172		-	,
173		-	ORGANIZATION, OR PBM PURSUANT TO SUBSECTION (4)(b)(II) OF THIS
174		-	SECTION OR SECTION
175		-	10-16-124.5 (5.5), AS APPLICABLE. THE CARRIER SHALL
176		-	INCLUDE THE FOLLOWING DATA
177		-	:
	233	+	HE PRESCRIPTION DRUG, DIAGNOSTIC TEST, PROCEDURE, OR11
	234	+	OTHER HEALTH-CARE SERVICE FOR WHICH AN EXEMPTION OR12
	235	+	ALTERNATIVE PROGRAM WAS OFFERED .13
	236	+	(V) T
	237	+	HE COMMISSIONER SHALL ADOPT RULES
	238	+	TO:14
	239	+	(A) IMPLEMENT SUBSECTIONS (2)(c)(I) AND (2)(c)(IV) OF THIS15
	240	+	SECTION TO ENSURE THAT THE DATA FIELDS REQUIRED TO BE POSTED16
	241	+	PURSUANT TO SUBSECTIONS (2)(c)(I) AND (2)(c)(IV) OF THIS SECTION ARE17
	242	+	PRESENTED CONSISTENTLY BY CARRIERS; AND18
	243	+	(B) DEFINE CATEGORIES OF PRIOR AUTHORIZATION REQUEST19
	244	+	DENIALS FOR PURPOSES OF SUBSECTION (2)(c)(I)(C) OF THIS SECTION.20
	245	+	(3) Nonurgent and urgent health-care services - timely21
	246	+	determination - notice of determination - deemed approved.22
	247	+	(a) Except as provided in subsection (3)(b) of this section, a prior23
	248	+	authorization request is deemed granted if a carrier or organization fails24
	249	+	to:25
	250	+	(I) (A) Notify the provider and covered person, within five26
	251	+	business days after receipt of the request, that the request is approved,27
	252	+	1149
	253	+	-7- denied, or incomplete and INDICATE: If DENIED, WHAT RELEVANT1
	254	+	ALTERNATIVE SERVICES OR TREATMENTS MAY BE A COVERED BENEFIT OR2
	255	+	ARE REQUIRED BEFORE APPROVAL OF THE DENIED SERVICE OR3
	256	+	TREATMENT; OR IF incomplete, indicate the specific additional4
	257	+	information, consistent with criteria posted pursuant to subsection (2)(a)5
	258	+	of this section, that is required to process the request; or6
	259	+	(B) Notify the provider and covered person, within five business7
	260	+	days after receiving the additional information required by the carrier or8
	261	+	organization pursuant to subsection (3)(a)(I)(A) of this section, that the9
	262	+	request is approved or denied AND, IF DENIED, INDICATE WHAT RELEVANT10
	263	+	ALTERNATIVE SERVICES OR TREATMENTS MAY BE A COVERED BENEFIT OR11
	264	+	ARE REQUIRED BEFORE APPROVAL OF THE DENIED SERVICE OR12
	265	+	TREATMENT; and13
	266	+	(c) (II) If the carrier or organization denies a prior authorization14
	267	+	request based on a ground specified in section 10-16-113 (3)(a), the15
	268	+	notification is subject to the requirements of section 10-16-113 (3)(a) and16
	269	+	commissioner rules adopted pursuant to that section and must:17
	270	+	(A) Include information concerning whether the carrier or18
	271	+	organization requires an alternative treatment, test, procedure, or19
	272	+	medication
	273	+	AND WHAT ALTERNATIVE SERVICES OR
	274	+	TREATMENTS WOULD20
	275	+	BE APPROVED AS A COVERED BENEFIT UNDER THE HEALTH BENEFIT PLAN;21
	276	+	OR22
	277	+	(B) IN THE CASE OF THE DENIAL OF A PRIOR AUTHORIZATION23
	278	+	REQUEST FOR A PRESCRIPTION DRUG, SPECIFY WHICH PRESCRIPTION DRUGS24
	279	+	AND DOSAGES IN THE SAME CLASS AS THE PRESCRIPTION DRUG FOR WHICH25
	280	+	THE PRIOR AUTHORIZATION REQUEST WAS DENIED ARE COVERED26
	281	+	PRESCRIPTION DRUGS UNDER THE HEALTH BENEFIT PLAN .27
	282	+	1149
	283	+	-8- (III) A CARRIER'S, ORGANIZATION'S, OR PHARMACY BENEFIT1
	284	+	MANAGER'S COMPLIANCE WITH THIS SUBSECTION (3)(c)(II) DOES NOT2
	285	+	CONSTITUTE THE PRACTICE OF MEDICINE .3
	286	+	(3.5) (a) STARTING JANUARY 1, 2027, A CARRIER OR4
	287	+	ORGANIZATION SHALL HAVE, MAINTAIN, AND USE A PRIOR AUTHORIZATION5
	288	+	APPLICATION PROGRAMMING INTERFACE THAT AUTOMATES THE PRIOR6
	289	+	AUTHORIZATION PROCESS TO ENABLE A PROVIDER TO :7
	290	+	(I) DETERMINE WHETHER PRIOR AUTHORIZATION IS REQUIRED FOR8
	291	+	A HEALTH-CARE SERVICE;9
	292	+	(II) IDENTIFY PRIOR AUTHORIZATION INFORMATION AND10
	293	+	DOCUMENTATION REQUIREMENTS ; AND11
	294	+	(III) FACILITATE THE EXCHANGE OF PRIOR AUTHORIZATION12
	295	+	REQUESTS AND DETERMINATIONS FROM THE PROVIDER'S ELECTRONIC13
	296	+	HEALTH RECORDS OR PRACTICE MANAGEMENT SYSTEMS THR OUGH SECURE14
	297	+	ELECTRONIC TRANSMISSION.15
	298	+	(b) A CARRIER'S OR ORGANIZATION'S APPLICATION PROGRAMMING16
	299	+	INTERFACE MUST MEET THE MOST RECENT STANDARDS AND17
	300	+	IMPLEMENTATION SPECIFICATIONS ADOPTED BY THE SECRETARY OF THE18
	301	+	UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES AS19
	302	+	SPECIFIED IN 45 CFR 170.215 (a).20
	303	+	(c) IF A PROVIDER SUBMITS A PRIOR AUTHORIZATION REQUEST21
	304	+	THROUGH THE CARRIER'S OR ORGANIZATION'S APPLICATION PROGRAMMING22
	305	+	INTERFACE, THE CARRIER OR ORGANIZATION SHALL ACCEPT AND RESPOND23
	306	+	TO THE REQUEST THROUGH THE INTERFACE .24
	307	+	(4) Criteria, limits, and exceptions. (b) (I) Carriers and25
	308	+	organizations shall consider limiting the use of prior authorization to26
	309	+	providers whose prescribing or ordering patterns differ significantly from27
	310	+	1149
	311	+	-9- the patterns of their peers after adjusting for patient mix and other1
	312	+	relevant factors and present opportunities for improvement in adherence2
	313	+	to the carrier's or organization's prior authorization requirements.3
	314	+	(II) (A) NO LATER THAN JANUARY 1, 2026, a carrier or AN4
	315	+	organization may offer providers with a history of adherence to the5
	316	+	carrier's or organization's prior authorization requirements at least one6
	317	+	alternative to prior authorization, including an exemption from prior7
	318	+	authorization requirements for a provider that has at least an eighty8
	319	+	percent approval rate of prior authorization requests over the immediately9
	320	+	preceding twelve months. SHALL ADOPT A PROGRAM , DEVELOPED IN10
	321	+	CONSULTATION WITH PROVIDERS PARTICIPATING WITH THE CARRIER , TO11
	322	+	ELIMINATE OR SUBSTANTIALLY MODIFY PRIOR AUTHORIZATION12
	323	+	REQUIREMENTS IN A MANNER THAT REMOVES THE ADMINISTRATIVE13
	324	+	BURDEN FOR QUALIFIED PROVIDERS , AS DEFINED UNDER THE PROGRAM ,14
	325	+	AND THEIR PATIENTS FOR CERTAIN HEALTH-CARE SERVICES AND RELATED15
	326	+	BENEFITS BASED ON ANY OF THE FOLLOWING :16
178	327		(A) T
179		-	HE NUMBER OF PROVIDERS OFFERED AN EXEMPTION OR
180		-	ALTERNATIVE PROGRAM
181		-	, INCLUDING THEIR SPECIALTY AREAS;
	328	+	HE PERFORMANCE OF PROVIDERS WITH RESPECT TO17
	329	+	ADHERENCE TO NATIONALLY RECOGNIZED , EVIDENCE-BASED MEDICAL18
	330	+	GUIDELINES, APPROPRIATENESS, EFFICIENCY, AND OTHER QUALITY19
	331	+	CRITERIA; AND20
	332	+	(B) P
	333	+	ROVIDER SPECIALTY, EXPERIENCE, OR OTHER OBJECTIVE21
	334	+	FACTORS; EXCEPT THAT ELIGIBILITY FOR THE PROGRAM MUST NOT BE22
	335	+	LIMITED BY PROVIDER SPECIALTY.23
	336	+	(III) A
	337	+	PROGRAM DEVELOPED PURSUANT TO SUBSECTION (4)(b)(II)24
	338	+	OF THIS SECTION:25
	339	+	(A) M
	340	+	UST NOT REQUIRE QUALIFIED PROVIDERS TO REQUEST26
	341	+	PARTICIPATION IN THE PROGRAM; AND27
	342	+	1149
	343	+	-10- (B) MAY INCLUDE LIMITING THE USE OF PRIOR AUTHORIZATION TO1
	344	+	PROVIDERS WHOSE PRESCRIBING OR ORDERING PATTERNS DIFFER2
	345	+	SIGNIFICANTLY FROM THE PATTERNS OF THEIR PEERS AFTER ADJUSTING3
	346	+	FOR PATIENT MIX AND OTHER RELEVANT FACTORS AND IN ORDER TO4
	347	+	PRESENT THOSE PROVIDERS WITH OPPORTUNITIES FOR IMPROVEMENT IN5
	348	+	ADHERENCE TO THE CARRIER'S OR ORGANIZATION'S PRIOR AUTHORIZATION6
	349	+	REQUIREMENTS.7
	350	+	(IV) At least annually, a carrier or
	351	+	AN organization shall:8
	352	+	(A) Reexamine a provider's prescribing or ordering patterns; and
	353	+	9
	354	+	(B) Reevaluate the provider's status for exemption from or other10
	355	+	alternative to prior authorization requirements OR FOR INCLUSION IN THE11
	356	+	PROGRAM DEVELOPED pursuant to this subsection (4)(b)(II) OF THIS12
	357	+	SECTION; AND13
	358	+	(B) (C) The carrier or organization shall inform NOTIFY the14
	359	+	provider of the provider's
	360	+	STATUS FOR exemption status and provide
	361	+	15
	362	+	information on the data considered as part of its reexamination of the16
	363	+	provider's prescribing or ordering patterns for the twelve-month period of17
	364	+	review OR INCLUSION IN THE PROGRAM.18
	365	+	(V) A
	366	+	PROGRAM DEVELOPED PURSUANT TO SUBSECTION (4)(b)(II)19
	367	+	OF THIS SECTION MUST INCLUDE PROCEDURES FOR A PROVIDER TO20
	368	+	REQUEST:21
	369	+	(A) A
	370	+	N EXPEDITED, INFORMAL RESOLUTION OF A CARRIER'S OR AN22
	371	+	ORGANIZATION'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE23
	372	+	PROGRAM; AND24
	373	+	(B) I
	374	+	F THE MATTER IS NOT RESOLVED THROUGH INFORMAL25
	375	+	RESOLUTION, BINDING ARBITRATION AS SPECIFIED IN SUBSECTION26
	376	+	(4)(b)(VI) OF THIS SECTION.27
	377	+	1149
	378	+	-11- (VI) IF A PROVIDER REQUESTS BINDING ARBITRATION PURSUANT1
	379	+	TO THE PROCEDURES A CARRIER OR AN ORGANIZATION DEVELOPS UNDER2
	380	+	SUBSECTION (4)(b)(V)(B) OF THIS SECTION, THE FOLLOWING PROVISIONS3
	381	+	GOVERN THE ARBITRATION PROCEDURE :4
	382	+	(A) THE PROVIDER AND CARRIER OR ORGANIZATION SHALL5
	383	+	JOINTLY SELECT AN ARBITRATOR FROM THE LIST OF ARBITRATORS6
	384	+	APPROVED PURSUANT TO SECTION 10-16-704 (15)(b). NEITHER THE7
	385	+	PROVIDER NOR THE CARRIER OR ORGANIZATION IS REQUIRED TO NOTIFY8
	386	+	THE DIVISION OF THE ARBITRATION OR OF THE SELECTED ARBITRATOR .9
	387	+	(B) THE SELECTED ARBITRATOR SHALL DETERMINE THE10
	388	+	PROVIDER'S ELIGIBILITY TO PARTICIPATE IN THE CARRIER 'S OR11
	389	+	ORGANIZATION'S PROGRAM BASED ON THE PROGRAM CRITERIA DEVELOPED12
	390	+	PURSUANT TO SUBSECTION (4)(b)(II) OF THIS SECTION;13
	391	+	(C) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR14
	392	+	ACCEPTS THE MATTER , THE PROVIDER AND THE CARRIER OR15
	393	+	ORGANIZATION SHALL SUBMIT TO THE ARBITRATOR WRITTEN MATERIALS16
	394	+	IN SUPPORT OF THEIR RESPECTIVE POSITIONS;17
	395	+	(D) THE ARBITRATOR MAY RENDER A DECISION BASED ON THE18
	396	+	WRITTEN MATERIALS SUBMITTED PURSUANT TO SUBSECTION (4)(b)(VI)(C)19
	397	+	OF THIS SECTION OR MAY SCHEDULE A HEARING, LASTING NOT LONGER20
	398	+	THAN ONE DAY, FOR THE PROVIDER AND CARRIER OR ORGANIZATION TO21
	399	+	PRESENT EVIDENCE;22
	400	+	(E) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR23
	401	+	RECEIVES THE WRITTEN MATERIALS OR, IF A HEARING IS CONDUCTED, THE24
	402	+	DATE OF THE HEARING, THE ARBITRATOR SHALL ISSUE A WRITTEN25
	403	+	DECISION STATING WHETHER THE PROVIDER IS ELIGIBLE FOR THE26
	404	+	PROGRAM; AND27
	405	+	1149
	406	+	-12- (F) IF THE ARBITRATOR OVERTURNS THE CARRIER 'S OR1
	407	+	ORGANIZATION'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE2
	408	+	PROGRAM, THE CARRIER OR ORGANIZATION SHALL PAY THE ARBITRATOR'S3
	409	+	FEES AND COSTS, AND IF THE ARBITRATOR AFFIRMS THE CARRIER'S OR4
	410	+	ORGANIZATION'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE5
	411	+	PROGRAM, THE PROVIDER SHALL PAY THE ARBITRATOR'S FEES AND COSTS.6
	412	+	7
	413	+	(c) (I) WHEN A CARRIER OR AN ORGANIZATION APPROVES A PRIOR8
	414	+	AUTHORIZATION REQUEST FOR A SURGICAL PROCEDURE FOR WHICH PRIOR9
	415	+	AUTHORIZATION IS REQUIRED, THE CARRIER OR ORGANIZATION SHALL NOT10
	416	+	DENY A CLAIM FOR AN ADDITIONAL OR A RELATED HEALTH -CARE11
	417	+	PROCEDURE IDENTIFIED DURING THE AUTHORIZED SURGICAL PROCEDURE12
	418	+	IF:13
	419	+	(A) T
	420	+	HE PROVIDER, WHILE PROVIDING THE APPROVED SURGICAL14
	421	+	PROCEDURE TO TREAT THE COVERED PERSON , DETERMINES, IN15
	422	+	ACCORDANCE WITH GENERALLY ACCEPTED STANDARDS OF MEDICAL16
	423	+	PRACTICE, THAT PROVIDING A RELATED HEALTH -CARE PROCEDURE,17
	424	+	INSTEAD OF OR IN ADDITION TO THE APPROVED SURGICAL PROCEDURE , IS18
	425	+	MEDICALLY NECESSARY AS PART OF THE TREATMENT OF THE COVERED19
	426	+	PERSON AND THAT, IN THE PROVIDER'S CLINICAL JUDGMENT, TO INTERRUPT20
	427	+	OR DELAY THE PROVISION OF CARE TO THE COVERED PERSON IN ORDER TO21
	428	+	OBTAIN PRIOR AUTHORIZATION FOR THE ADDITIONAL OR RELATED22
	429	+	HEALTH-CARE PROCEDURE WOULD NOT BE MEDICALLY ADVISABLE ;23
182	430		(B) T
183		-	HE NUMBER AND CATEGORIZED TYPES OF EXEMPTIONS OR
184		-	ALTERNATIVE PROGRAMS OFFERED TO PROVIDERS
185		-	; AND
186		-	(C) THE PRESCRIPTION DRUG, DIAGNOSTIC TEST, PROCEDURE, OR
187		-	OTHER HEALTH
188		-	-CARE SERVICE FOR WHICH AN EXEMPTION OR ALTERNATIVE
189		-	PROGRAM WAS OFFERED
190		-	.
191		-	(V) T
192		-	HE COMMISSIONER SHALL ADOPT RULES TO :
193		-	(A) I
194		-	MPLEMENT SUBSECTIONS (2)(c)(I) AND (2)(c)(IV) OF THIS
195		-	SECTION TO ENSURE THAT THE DATA FIELDS REQUIRED TO BE POSTED
196		-	PURSUANT TO SUBSECTIONS
197		-	(2)(c)(I) AND (2)(c)(IV) OF THIS SECTION ARE
198		-	PRESENTED CONSISTENTLY BY CARRIERS
199		-	; AND
200		-	(B) DEFINE CATEGORIES OF PRIOR AUTHORIZATION REQUEST
201		-	PAGE 5-HOUSE BILL 24-1149 DENIALS FOR PURPOSES OF SUBSECTION (2)(c)(I)(C) OF THIS SECTION.
202		-	(3) Nonurgent and urgent health-care services - timely
203		-	determination - notice of determination - deemed approved. (a) Except
204		-	as provided in subsection (3)(b) of this section, a prior authorization request
205		-	is deemed granted if a carrier or organization fails to:
206		-	(I) (A) Notify the provider and covered person, within five business
207		-	days after receipt of the request, that the request is approved, denied, or
208		-	incomplete and
209		-	INDICATE: IF DENIED, WHAT RELEVANT ALTERNATIVE
210		-	SERVICES OR TREATMENTS MAY BE A COVERED BENEFIT OR ARE REQUIRED
211		-	BEFORE APPROVAL OF THE DENIED SERVICE OR TREATMENT
212		-	; OR if
213		-	incomplete, indicate
214		-	the specific additional information, consistent with
215		-	criteria posted pursuant to subsection (2)(a) of this section, that is required
216		-	to process the request; or
217		-	(B) Notify the provider and covered person, within five business
218		-	days after receiving the additional information required by the carrier or
219		-	organization pursuant to subsection (3)(a)(I)(A) of this section, that the
220		-	request is approved or denied
221		-	AND, IF DENIED, INDICATE WHAT RELEVANT
222		-	ALTERNATIVE SERVICES OR TREATMENTS MAY BE A COVERED BENEFIT OR
223		-	ARE REQUIRED BEFORE APPROVAL OF THE DENIED SERVICE OR TREATMENT
224		-	;
225		-	and
226		-	(c) (II) If the carrier or organization denies a prior authorization
227		-	request based on a ground specified in section 10-16-113 (3)(a), the
228		-	notification is subject to the requirements of section 10-16-113 (3)(a) and
229		-	commissioner rules adopted pursuant to that section and must:
230		-	(A) Include information concerning whether the carrier or
231		-	organization requires an alternative treatment, test, procedure, or medication
232		-	AND WHAT ALTERNATIVE SERVICES OR TREATMENTS WOULD BE APPROVED
233		-	AS A COVERED BENEFIT UNDER THE HEALTH BENEFIT PLAN
234		-	; OR
235		-	(B) IN THE CASE OF THE DENIAL OF A PRIOR AUTHORIZATION
236		-	REQUEST FOR A PRESCRIPTION DRUG
237		-	, SPECIFY WHICH PRESCRIPTION DRUGS
238		-	AND DOSAGES IN THE SAME CLASS AS THE PRESCRIPTION DRUG FOR WHICH
239		-	THE PRIOR AUTHORIZATION REQUEST WAS DENIED ARE COVERED
240		-	PRESCRIPTION DRUGS UNDER THE HEALTH BENEFIT PLAN
241		-	.
242		-	PAGE 6-HOUSE BILL 24-1149 (III) A CARRIER'S, ORGANIZATION'S, OR PHARMACY BENEFIT
243		-	MANAGER
244		-	'S COMPLIANCE WITH SUBSECTION (3)(c)(II) OF THIS SECTION DOES
245		-	NOT CONSTITUTE THE PRACTICE OF MEDICINE
246		-	.
247		-	(3.5) (a) S
248		-	TARTING JANUARY 1, 2027, A CARRIER OR ORGANIZATION
249		-	SHALL HAVE
250		-	, MAINTAIN, AND USE A PRIOR AUTHORIZATION APPLICATION
251		-	PROGRAMMING INTERFACE THAT AUTOMATES THE PRIOR AUTHORIZATION
252		-	PROCESS TO ENABLE A PROVIDER TO
253		-	:
254		-	(I) D
255		-	ETERMINE WHETHER PRIOR AUTHORIZATION IS REQUIRED FOR
256		-	A HEALTH
257		-	-CARE SERVICE;
258		-	(II) I
259		-	DENTIFY PRIOR AUTHORIZATION INFORMATION AND
260		-	DOCUMENTATION REQUIREMENTS
261		-	; AND
262		-	(III) FACILITATE THE EXCHANGE OF PRIOR AUTHORIZATION
263		-	REQUESTS AND DETERMINATIONS FROM THE PROVIDER
264		-	'S ELECTRONIC
265		-	HEALTH RECORDS OR PRACTICE MANAGEMENT SYSTEMS THROUGH SECURE
266		-	ELECTRONIC TRANSMISSION
267		-	.
	431	+	HE ADDITIONAL OR RELATED HEALTH -CARE PROCEDURE IS A24
	432	+	COVERED BENEFIT UNDER THE COVERED PERSON 'S HEALTH BENEFIT PLAN;25
	433	+	(C) T
	434	+	HE ADDITIONAL OR RELATED HEALTH -CARE PROCEDURE IS26
	435	+	NOT EXPERIMENTAL OR INVESTIGATIONAL ;27
	436	+	1149
	437	+	-13- (D) AFTER COMPLETING THE ADDITIONAL OR RELATED1
	438	+	HEALTH-CARE PROCEDURE AND BEFORE SUBMITTING A CLAIM FOR2
	439	+	PAYMENT, THE PROVIDER NOTIFIES THE CARRIER OR ORGANIZATION THAT3
	440	+	THE PROVIDER PERFORMED THE ADDITIONAL OR RELATED HEALTH -CARE4
	441	+	PROCEDURE AND INCLUDES IN THE NOTICE THE INFORMATION REQUIRED5
	442	+	UNDER THE CARRIER 'S OR ORGANIZATION 'S CURRENT PRIOR6
	443	+	AUTHORIZATION REQUIREMENTS POSTED IN ACCORDANCE WITH7
	444	+	SUBSECTION (2)(a)(I) OF THIS SECTION; AND8
	445	+	(E) T
	446	+	HE PROVIDER IS COMPLIANT WITH THE CARRIER 'S OR9
	447	+	ORGANIZATION'S POST-SERVICE CLAIMS PROCESS, INCLUDING SUBMISSION10
	448	+	OF THE CLAIM WITHIN THE CARRIER 'S OR ORGANIZATION'S REQUIRED11
	449	+	TIMELINE FOR CLAIMS SUBMISSIONS.12
	450	+	(II) W
	451	+	HEN A PROVIDER PROVIDES AN ADDITIONAL OR A RELATED13
	452	+	HEALTH-CARE PROCEDURE AS DESCRIBED IN THIS SUBSECTION
	453	+	(4)(c), THE14
	454	+	CARRIER OR ORGANIZATION SHALL NOT DENY THE CLAIM FOR THE INITIAL15
	455	+	SURGICAL PROCEDURE FOR WHICH THE CARRIER OR ORGANIZATION16
	456	+	APPROVED A PRIOR AUTHORIZATION REQUEST ON THE BASIS THAT THE17
	457	+	PROVIDER PROVIDED THE ADDITIONAL OR RELATED HEALTH -CARE18
	458	+	PROCEDURE.19
	459	+	(5) Duration of approval. (a) Upon approval by the carrier or20
	460	+	organization, a prior authorization is valid for at least one hundred eighty21
	461	+	days CALENDAR YEAR after the date of approval and continues for the22
	462	+	duration of the authorized course of treatment. Except as provided in23
	463	+	subsection (5)(b) of this section, once approved, a carrier or
	464	+	AN24
	465	+	organization shall not retroactively deny the prior authorization request25
	466	+	for a health-care service.26
	467	+	(6) Rules - enforcement. (a) The commissioner may adopt rules27
	468	+	1149
	469	+	-14- as necessary to implement this section.1
	470	+	(b) T
	471	+	HE COMMISSIONER MAY ENFORCE THE REQUIREMENTS OF THIS2
	472	+	SECTION AND IMPOSE A PENALTY OR OTHER REMEDY AGAINST A PERSON3
	473	+	THAT VIOLATES THIS SECTION.4
	474	+	(7) Definitions. As used in this section:5
	475	+	(e) "Private utilization review organization" or "organization" has
	476	+	6
	477	+	the same meaning as set forth MEANS A PRIVATE UTILIZATION REVIEW7
	478	+	ORGANIZATION, AS DEFINED in section 10-16-112 (1)(a), THAT HAS A8
	479	+	CONTRACT WITH AND PERFORMS PRIOR AUTHORIZATION ON BEHALF OF A9
	480	+	CARRIER.10
	481	+	11
	482	+	SECTION 3. In Colorado Revised Statutes, 10-16-124.5, amend12
	483	+	(2)(a)(II)(A), (2)(c)(II)(A), (3)(a) introductory portion, (3)(a)(I),13
	484	+	(3)(a)(VI), (3)(b) introductory portion, (5), and (6); repeal (3)(a)(II) and14
	485	+	(4); and add (3.3), (3.5), (5.5), and (6.5) as follows:15
	486	+	10-16-124.5. Prior authorization form - drug benefits - rules16
	487	+	of commissioner - definitions - repeal. (2) (a) Except as provided in17
	488	+	subsection (2)(b) or (2)(c) of this section, a prior authorization request is18
	489	+	deemed granted if a carrier or pharmacy benefit management firm fails to:19
	490	+	(II) For prior authorization requests submitted electronically:20
	491	+	(A) Notify the prescribing provider, within two business days after21
	492	+	receipt of the request, that the request is approved, denied, or incomplete,22
	493	+	and if incomplete, indicate the specific additional information, consistent23
	494	+	with criteria posted pursuant to subparagraph (II) of paragraph (a) of24
	495	+	subsection (3) SUBSECTION (3.5)(a) of this section, that is required to25
	496	+	process the request; or26
	497	+	(c) For nonurgent prior authorization requests related to a covered27
	498	+	1149
	499	+	-15- person's HIV prescription drug coverage, the prior authorization request1
	500	+	is deemed granted if a carrier or pharmacy benefit management firm fails2
	501	+	to:3
	502	+	(II) For prior authorization requests submitted electronically:4
	503	+	(A) Notify the prescribing provider within one business day after5
	504	+	receipt of the request that the request is approved, denied, or incomplete,6
	505	+	and if incomplete, indicate the specific additional information, consistent7
	506	+	with criteria posted pursuant to subsection (3)(a)(II) SUBSECTION (3.5)(a)8
	507	+	of this section, that is required to process the request; or9
	508	+	(3) (a) On or before July 31, 2014, The commissioner shall10
	509	+	develop, by rule, a uniform prior authorization process that:11
	510	+	(I) Is made available electronically by the carrier or pharmacy12
	511	+	benefit management firm, but that does not require the prescribing13
	512	+	provider to submit a prior authorization request electronically, AND14
	513	+	SATISFIES THE REQUIREMENTS OF SUBSECTION (3.3) OF THIS SECTION;15
	514	+	(II) Requires each carrier and pharmacy benefit management firm16
	515	+	to make the following available and accessible in a centralized location17
	516	+	on its website:18
	517	+	(A) Its prior authorization requirements and restrictions, including19
	518	+	a list of drugs that require prior authorization;20
	519	+	(B) Written clinical criteria that are easily understandable to the21
	520	+	prescribing provider and that include the clinical criteria for22
	521	+	reauthorization of a previously approved drug after the prior authorization23
	522	+	period has expired; and24
	523	+	(C) The standard form for submitting requests;25
	524	+	(VI) Requires carriers and pharmacy benefit management firms,26
	525	+	when notifying a prescribing provider of its decision to deny a prior27
	526	+	1149
	527	+	-16- authorization request, to include THE INFORMATION REQUIRED BY SECTION1
	528	+	10-16-112.5 (3)(c)(II) AND a notice that the covered person has a right to2
	529	+	appeal the adverse determination pursuant to sections 10-16-113 and3
	530	+	10-16-113.5.4
	531	+	(b) In developing the uniform prior authorization process, the5
	532	+	commissioner shall take into consideration the recommendations, if any,6
	533	+	of the work group established pursuant to subsection (4) of this section7
	534	+	and the following:8
	535	+	(3.3) STARTING JANUARY 1, 2027, IF A PROVIDER SUBMITS A PRIOR9
	536	+	AUTHORIZATION REQUEST TO A CARRIER OR PBM THROUGH A SECURE10
	537	+	ELECTRONIC TRANSMISSION SYSTEM THE CARRIER OR PBM USES THAT11
	538	+	COMPLIES WITH THE MOST RECENT VERSION OF THE NATIONAL COUNCIL12
	539	+	FOR PRESCRIPTION DRUG PROGRAMS SCRIPT STANDARD, OR ITS13
	540	+	SUCCESSOR STANDARD, AND 21 CFR 1311, THE CARRIER OR PBM SHALL14
	541	+	ACCEPT AND RESPOND TO THE REQUEST THOUGH THE SECURE ELECTRONIC15
	542	+	TRANSMISSION SYSTEM.16
	543	+	(3.5) (a) O
	544	+	N AND AFTER JANUARY 1, 2026, A CARRIER SHALL POST17
	545	+	ON THE CARRIER'S PUBLIC-FACING WEBSITE, IN A READILY ACCESSIBLE,18
	546	+	STANDARDIZED, SEARCHABLE FORMAT , PRIOR AUTHORIZATION19
	547	+	REQUIREMENTS AS APPLICABLE TO THE PRESCRIPTION DRUG FORMULARY20
	548	+	FOR EACH HEALTH BENEFIT PLAN THE CARRIER OFFERS , INCLUDING THE21
	549	+	FOLLOWING INFORMATION :22 (I) THE CARRIER'S PRIOR AUTHORIZATION REQUIREMENTS AND23
	550	+	RESTRICTIONS, INCLUDING A LIST OF DRUGS THAT REQUIRE PRIOR24
	551	+	AUTHORIZATION;25
	552	+	(II) WRITTEN CLINICAL CRITERIA THAT ARE EASILY26
	553	+	UNDERSTANDABLE TO THE PRESCRIBING PROVIDER AND THAT INCLUDE THE27
	554	+	1149
	555	+	-17- CLINICAL CRITERIA FOR REAUTHORIZATION OF A PREVIOUSLY APPROVED1
	556	+	DRUG AFTER THE PRIOR AUTHORIZATION PERIOD HAS EXPIRED ;2
	557	+	(III) THE STANDARD FORM FOR SUBMITTING PRIOR AUTHORIZATION3
	558	+	REQUESTS;4
	559	+	(IV) THE HEALTH BENEFIT PLAN TO WHICH THE FORMULARY5
	560	+	APPLIES;6
	561	+	(V) EACH PRESCRIPTION DRUG THAT IS COVERED UNDER THE7
	562	+	HEALTH BENEFIT PLAN, INCLUDING BOTH GENERIC AND BRAND -NAME8
	563	+	VERSIONS OF A PRESCRIPTION DRUG;9
	564	+	(VI) ANY PRESCRIPTION DRUGS ON THE FORMULARY THAT ARE10
	565	+	PREFERRED OVER OTHER PRESCRIPTION DRUGS OR ANY ALTERNATIVE11
	566	+	PRESCRIPTION DRUGS THAT DO NOT REQUIRE PRIOR AUTHORIZATION ;12
	567	+	(VII) ANY EXCLUSIONS FROM OR RESTRICTIONS ON COVERAGE ,13
	568	+	INCLUDING:14
	569	+	(A) A
	570	+	NY TIERING STRUCTURE, INCLUDING COPAYMENT AND15
	571	+	COINSURANCE REQUIREMENTS ;16
	572	+	(B) P
	573	+	RIOR AUTHORIZATION, STEP THERAPY, AND OTHER17
	574	+	UTILIZATION MANAGEMENT CONTROLS ;18
	575	+	(C) Q
	576	+	UANTITY LIMITS; AND19
	577	+	(D) W
	578	+	HETHER ACCESS IS DEPENDENT UPON THE LOCATION WHERE20
	579	+	A PRESCRIPTION DRUG IS OBTAINED OR ADMINISTERED ; AND21
	580	+	(VIII) THE APPEAL PROCESS FOR A DENIAL OF COVERAGE OR22
	581	+	ADVERSE DETERMINATION FOR AN ITEM OR SERVICE FOR A PRESCRIPTION23
	582	+	DRUG.24
	583	+	(b) T
	584	+	HE COMMISSIONER SHALL ADOPT RULES AS NECESSARY TO25
	585	+	IMPLEMENT THIS SUBSECTION (3.5).26
	586	+	(4) (a) Within thirty days after May 15, 2013, the commissioner
	587	+	27
	588	+	1149
	589	+	-18- shall establish a work group comprised of representatives of:1
	590	+	(I) The department of regulatory agencies;2
	591	+	(II) Local and national carriers;3
	592	+	(III) Captive and noncaptive pharmacy benefit management firms;4
	593	+	(IV) Providers, including hospitals, physicians, advanced practice5
	594	+	registered nurses with prescriptive authority, and pharmacists;6
	595	+	(V) Drug manufacturers;7
	596	+	(VI) Medical practice managers;8
	597	+	(VII) Consumers; and9
	598	+	(VIII) Other stakeholders deemed appropriate by the10
	599	+	commissioner.11
	600	+	(b) The work group shall assist the commissioner in developing12
	601	+	the prior authorization process and shall make recommendations to the13
	602	+	commissioner on the items set forth in paragraph (b) of subsection (3) of14
	603	+	this section. The work group shall report its recommendations to the15
	604	+	commissioner no later than six months after the commissioner appoints16
	605	+	the work group members. Regardless of whether the work group submits17
	606	+	recommendations to the commissioner, the commissioner shall not delay18
	607	+	or extend the deadline for the adoption of rules creating the prior19
	608	+	authorization process as specified in paragraph (a) of subsection (3) of20
	609	+	this section.21
	610	+	(5) (a) Notwithstanding any other provision of law, on and after22
	611	+	January 1, 2015 AND EXCEPT AS PROVIDED IN SUBSECTIONS (5)(b) AND23
	612	+	(5.5)
	613	+	OF THIS SECTION, every prescribing provider shall use the prior24
	614	+	authorization process developed pursuant to subsection (3) of this section25
	615	+	to request prior authorization for coverage of drug benefits, and every26
	616	+	carrier and pharmacy benefit management firm shall use that process for27
	617	+	1149
	618	+	-19- prior authorization for drug benefits.1
	619	+	(b) (I) A
	620	+	CARRIER OR PBM THAT PROVIDES DRUG BENEFITS UNDER2
	621	+	A HEALTH BENEFIT PLAN SHALL NOT IMPOSE PRIOR AUTHORIZATION3
	622	+	REQUIREMENTS UNDER THE HEALTH BENEFIT PLAN
	623	+	MORE THAN ONCE4
	624	+	EVERY THREE YEARS FOR A DRUG THAT IS APPROVED BY THE FDA AND5
	625	+	THAT IS A CHRONIC MAINTENANCE DRUG IF THE CARRIER OR PBM HAS6
	626	+	PREVIOUSLY APPROVED A PRIOR AUTHORIZATION FOR THE COVERED7
	627	+	PERSON FOR USE OF THE CHRONIC MAINTENANCE DRUG .8
	628	+	(II) THIS SUBSECTION (5)(b) DOES NOT APPLY IF:9
	629	+	(A) THERE IS EVIDENCE THAT THE AUTHORIZATION WAS OBTAINED10
	630	+	FROM THE CARRIER OR PBM BASED ON FRAUD OR MISREPRESENTATION ;11
	631	+	(B) FINAL ACTION BY THE FDA OR OTHER REGULATORY AGENCIES,12
	632	+	OR THE MANUFACTURER, REMOVES THE CHRONIC MAINTENANCE DRUG13
	633	+	FROM THE MARKET, LIMITS ITS USE IN A MANNER THAT AFFECTS THE14
	634	+	AUTHORIZATION, OR COMMUNICATES A PATIENT SAFETY ISSUE THAT15
	635	+	WOULD AFFECT THE AUTHORIZATION ALONE OR IN COMBINATION WITH16
	636	+	OTHER AUTHORIZATIONS;17
	637	+	(C) A GENERIC EQUIVALENT OR DRUG THAT IS BIOSIMILAR, AS18
	638	+	DEFINED IN 42 U.S.C. SEC. 262 (i)(2), TO THE PRESCRIBED CHRONIC19
	639	+	MAINTENANCE DRUG IS ADDED TO THE CARRIER'S OR PBM'S DRUG20
	640	+	FORMULARY; OR21
	641	+	(D) THE WHOLESALE ACQUISITION COST OF THE CHRONIC22
	642	+	MAINTENANCE DRUG EXCEEDS A DOLLAR AMOUNT AS ESTABLISHED BY23
	643	+	THE COMMISSIONER BY RULE, WHICH AMOUNT MUST BE NO LESS THAN24
	644	+	THIRTY THOUSAND DOLLARS FOR A TWELVE-MONTH SUPPLY OR FOR A25
	645	+	COURSE OF TREATMENT THAT IS LESS THAN TWELVE MONTHS IN26
	646	+	DURATION.27
	647	+	1149
	648	+	-20- (III) NOTHING IN THIS SUBSECTION (5)(b) REQUIRES A CARRIER OR1
	649	+	PBM TO PAY FOR A BENEFIT:2
	650	+	(A) THAT IS NOT A COVERED BENEFIT UNDER THE HEALTH BENEFIT3
	651	+	PLAN; OR4
	652	+	(B) IF THE PATIENT IS NO LONGER A COVERED PERSON UNDER THE5
	653	+	HEALTH BENEFIT PLAN ON THE DATE THE CHRONIC MAINTENANCE DRUG6
	654	+	WAS PRESCRIBED, DISPENSED, ADMINISTERED, OR DELIVERED.7
	655	+	(IV) AS USED IN THIS SUBSECTION (5)(b), "CHRONIC MAINTENANCE8
	656	+	DRUG" HAS THE MEANING SET FORTH IN SECTION 12-280-103 (9.5).9
	657	+	10
	658	+	(5.5) (a) N
	659	+	O LATER THAN JANUARY 1, 2026, A CARRIER OR PBM11
	660	+	SHALL ADOPT A PROGRAM, DEVELOPED IN CONSULTATION WITH PROVIDERS12
	661	+	PARTICIPATING WITH THE CARRIER , TO ELIMINATE OR SUBSTANTIALLY13
	662	+	MODIFY PRIOR AUTHORIZATION REQUIREMENTS IN A MANNER THAT14
	663	+	REMOVES THE ADMINISTRATIVE BURDEN FOR QUALIFIED PROVIDERS , AS15
	664	+	DEFINED UNDER THE PROGRAM , AND THEIR PATIENTS FOR CERTAIN16
	665	+	PRESCRIPTION DRUGS AND RELATED DRUG BENEFITS BASED ON ANY OF THE17
	666	+	FOLLOWING:18
	667	+	(I) T
	668	+	HE PERFORMANCE OF PROVIDERS WITH RESPECT TO19
	669	+	ADHERENCE TO NATIONALLY RECOGNIZED , EVIDENCE-BASED MEDICAL20
	670	+	GUIDELINES, APPROPRIATENESS, EFFICIENCY, AND OTHER QUALITY21
	671	+	CRITERIA; AND22
	672	+	(II) P
	673	+	ROVIDER SPECIALTY, EXPERIENCE, OR OTHER OBJECTIVE23
	674	+	FACTORS; EXCEPT THAT ELIGIBILITY FOR THE PROGRAM MUST NOT BE24
	675	+	LIMITED BY PROVIDER SPECIALTY.25
268	676		(b) A
269		-	CARRIER'S OR ORGANIZATION'S APPLICATION PROGRAMMING
270		-	INTERFACE MUST MEET THE MOST RECENT STANDARDS AND
271		-	IMPLEMENTATION SPECIFICATIONS ADOPTED BY THE SECRETARY OF THE
272		-	UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES AS
273		-	SPECIFIED IN
274		-	45 CFR 170.215 (a).
275		-	(c) I
276		-	F A PROVIDER SUBMITS A PRIOR AUTHORIZATION REQUEST
277		-	THROUGH THE CARRIER
278		-	'S OR ORGANIZATION'S APPLICATION PROGRAMMING
279		-	INTERFACE
280		-	, THE CARRIER OR ORGANIZATION SHALL ACCEPT AND RESPOND
281		-	TO THE REQUEST THROUGH THE INTERFACE
282		-	.
283		-	(4) Criteria, limits, and exceptions. (b) (I) Carriers and
284		-	organizations shall consider limiting the use of prior authorization to
285		-	providers whose prescribing or ordering patterns differ significantly from
286		-	the patterns of their peers after adjusting for patient mix and other relevant
287		-	factors and present opportunities for improvement in adherence to the
288		-	carrier's or organization's prior authorization requirements.
289		-	(II) (A)
290		-	NO LATER THAN JANUARY 1, 2026, a carrier or AN
291		-	organization may offer providers with a history of adherence to the carrier's
292		-	PAGE 7-HOUSE BILL 24-1149 or organization's prior authorization requirements at least one alternative to
293		-	prior authorization, including an exemption from prior authorization
294		-	requirements for a provider that has at least an eighty percent approval rate
295		-	of prior authorization requests over the immediately preceding twelve
296		-	months. SHALL ADOPT A PROGRAM , DEVELOPED IN CONSULTATION WITH
297		-	PROVIDERS PARTICIPATING WITH THE CARRIER
298		-	, TO ELIMINATE OR
299		-	SUBSTANTIALLY MODIFY PRIOR AUTHORIZATION REQUIREMENTS IN A
300		-	MANNER THAT REMOVES THE ADMINISTRATIVE BURDEN FOR QUALIFIED
301		-	PROVIDERS
302		-	, AS DEFINED UNDER THE PROGRAM , AND THEIR PATIENTS FOR
303		-	CERTAIN HEALTH
304		-	-CARE SERVICES AND RELATED BENEFITS BASED ON ANY OF
305		-	THE FOLLOWING
306		-	:
307		-	(A) T
308		-	HE PERFORMANCE OF PROVIDERS WITH RESPECT TO ADHERENCE
309		-	TO NATIONALLY RECOGNIZED
310		-	, EVIDENCE-BASED MEDICAL GUIDELINES ,
311		-	APPROPRIATENESS, EFFICIENCY, AND OTHER QUALITY CRITERIA; AND
312		-	(B) PROVIDER SPECIALTY, EXPERIENCE, OR OTHER OBJECTIVE
313		-	FACTORS
314		-	; EXCEPT THAT ELIGIBILITY FOR THE PROGRAM MUST NOT BE
315		-	LIMITED BY PROVIDER SPECIALTY
316		-	.
317		-	(III) A
318		-	PROGRAM DEVELOPED PURSUANT TO SUBSECTION (4)(b)(II)
319		-	OF THIS SECTION:
320		-	(A) M
321		-	UST NOT REQUIRE QUALIFIED PROVIDERS TO REQUEST
322		-	PARTICIPATION IN THE PROGRAM
323		-	; AND
324		-	(B) MAY INCLUDE LIMITING THE USE OF PRIOR AUTHORIZATION TO
325		-	PROVIDERS WHOSE PRESCRIBING OR ORDERING PATTERNS DIFFER
326		-	SIGNIFICANTLY FROM THE PATTERNS OF THEIR PEERS AFTER ADJUSTING FOR
327		-	PATIENT MIX AND OTHER RELEVANT FACTORS AND IN ORDER TO PRESENT
328		-	THOSE PROVIDERS WITH OPPORTUNITIES FOR IMPROVEMENT IN ADHERENCE
329		-	TO THE CARRIER
330		-	'S OR ORGANIZATION 'S PRIOR AUTHORIZATION
331		-	REQUIREMENTS
332		-	.
333		-	(IV) At least annually, a carrier or
334		-	AN organization shall:
335		-	(A) Reexamine a provider's prescribing or ordering patterns; and
336		-	(B) Reevaluate the provider's status for exemption from or other
337		-	alternative to prior authorization requirements OR FOR INCLUSION IN THE
338		-	PAGE 8-HOUSE BILL 24-1149 PROGRAM DEVELOPED pursuant to this subsection (4)(b)(II) OF THIS
339		-	SECTION
340		-	; AND
341		-	(B)
342		-	(C) The carrier or organization shall inform NOTIFY the provider
343		-	of the provider's
344		-	STATUS FOR exemption status and provide information onthe data considered as part of its reexamination of the provider's prescribing
345		-	or ordering patterns for the twelve-month period of review OR INCLUSION
346		-	IN THE PROGRAM
347		-	.
348		-	(V) A
349		-	PROGRAM DEVELOPED PURSUANT TO SUBSECTION (4)(b)(II) OF
350		-	THIS SECTION MUST INCLUDE PROCEDURES FOR A PROVIDER TO REQUEST
351		-	:
352		-	(A) A
353		-	N EXPEDITED, INFORMAL RESOLUTION OF A CARRIER 'S OR AN
354		-	ORGANIZATION
355		-	'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE
356		-	PROGRAM
357		-	; AND
358		-	(B) IF THE MATTER IS NOT RESOLVED THROUGH INFORMAL
359		-	RESOLUTION
360		-	, BINDING ARBITRATION AS SPECIFIED IN SUBSECTION (4)(b)(VI)
361		-	OF THIS SECTION.
362		-	(VI) I
363		-	F A PROVIDER REQUESTS BINDING ARBITRATION PURSUANT TO
364		-	THE PROCEDURES A CARRIER OR AN ORGANIZATION DEVELOPS UNDER
365		-	SUBSECTION
366		-	(4)(b)(V)(B) OF THIS SECTION, THE FOLLOWING PROVISIONS
367		-	GOVERN THE ARBITRATION PROCEDURE
368		-	:
369		-	(A) T
370		-	HE PROVIDER AND CARRIER OR ORGANIZATION SHALL JOINTLY
371		-	SELECT AN ARBITRATOR FROM THE LIST OF ARBITRATORS APPROVED
372		-	PURSUANT TO SECTION
373		-	10-16-704 (15)(b). NEITHER THE PROVIDER NOR THE
374		-	CARRIER OR ORGANIZATION IS REQUIRED TO NOTIFY THE DIVISION OF THE
375		-	ARBITRATION OR OF THE SELECTED ARBITRATOR
376		-	.
377		-	(B) T
378		-	HE SELECTED ARBITRATOR SHALL DETERMINE THE PROVIDER 'S
379		-	ELIGIBILITY TO PARTICIPATE IN THE CARRIER
380		-	'S OR ORGANIZATION'S PROGRAM
381		-	BASED ON THE PROGRAM CRITERIA DEVELOPED PURSUANT TO SUBSECTION
382		-	(4)(b)(II) OF THIS SECTION;
383		-	(C) W
384		-	ITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
385		-	ACCEPTS THE MATTER
386		-	, THE PROVIDER AND THE CARRIER OR ORGANIZATION
387		-	SHALL SUBMIT TO THE ARBITRATOR WRITTEN MATERIALS IN SUPPORT OF
388		-	THEIR RESPECTIVE POSITIONS
389		-	;
390		-	PAGE 9-HOUSE BILL 24-1149 (D) THE ARBITRATOR MAY RENDER A DECISION BASED ON THE
391		-	WRITTEN MATERIALS SUBMITTED PURSUANT TO SUBSECTION
392		-	(4)(b)(VI)(C)
393		-	OF THIS SECTION OR MAY SCHEDULE A HEARING, LASTING NOT LONGER THAN
394		-	ONE DAY
395		-	, FOR THE PROVIDER AND CARRIER OR ORGANIZATION TO PRESENT
396		-	EVIDENCE
397		-	;
398		-	(E) W
399		-	ITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
400		-	RECEIVES THE WRITTEN MATERIALS OR
401		-	, IF A HEARING IS CONDUCTED, THE
402		-	DATE OF THE HEARING
403		-	, THE ARBITRATOR SHALL ISSUE A WRITTEN DECISION
404		-	STATING WHETHER THE PROVIDER IS ELIGIBLE FOR THE PROGRAM
405		-	; AND
406		-	(F) IF THE ARBITRATOR OVERTURNS THE CARRIER 'S OR
407		-	ORGANIZATION
408		-	'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE
409		-	PROGRAM
410		-	, THE CARRIER OR ORGANIZATION SHALL PAY THE ARBITRATOR 'S
411		-	FEES AND COSTS
412		-	, AND IF THE ARBITRATOR AFFIRMS THE CARRIER 'S OR
413		-	ORGANIZATION
414		-	'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE
415		-	PROGRAM
416		-	, THE PROVIDER SHALL PAY THE ARBITRATOR 'S FEES AND COSTS.
417		-	(c) (I) W
418		-	HEN A CARRIER OR AN ORGANIZATION APPROVES A PRIOR
419		-	AUTHORIZATION REQUEST FOR A SURGICAL PROCEDURE FOR WHICH PRIOR
420		-	AUTHORIZATION IS REQUIRED
421		-	, THE CARRIER OR ORGANIZATION SHALL NOT
422		-	DENY A CLAIM FOR AN ADDITIONAL OR A RELATED HEALTH
423		-	-CARE
424		-	PROCEDURE IDENTIFIED DURING THE AUTHORIZED SURGICAL PROCEDURE IF
425		-	:
426		-	(A) T
427		-	HE PROVIDER, WHILE PROVIDING THE APPROVED SURGICAL
428		-	PROCEDURE TO TREAT THE COVERED PERSON
429		-	, DETERMINES, IN ACCORDANCE
430		-	WITH GENERALLY ACCEPTED STANDARDS OF MEDICAL PRACTICE
431		-	, THAT
432		-	PROVIDING A RELATED HEALTH
433		-	-CARE PROCEDURE, INSTEAD OF OR IN
434		-	ADDITION TO THE APPROVED SURGICAL PROCEDURE
435		-	, IS MEDICALLY
436		-	NECESSARY AS PART OF THE TREATMENT OF THE COVERED PERSON AND
437		-	THAT
438		-	, IN THE PROVIDER'S CLINICAL JUDGMENT, TO INTERRUPT OR DELAY THE
439		-	PROVISION OF CARE TO THE COVERED PERSON IN ORDER TO OBTAIN PRIOR
440		-	AUTHORIZATION FOR THE ADDITIONAL OR RELATED HEALTH
441		-	-CARE
442		-	PROCEDURE WOULD NOT BE MEDICALLY ADVISABLE
443		-	;
444		-	(B) T
445		-	HE ADDITIONAL OR RELATED HEALTH -CARE PROCEDURE IS A
446		-	COVERED BENEFIT UNDER THE COVERED PERSON
447		-	'S HEALTH BENEFIT PLAN;
448		-	(C) T
449		-	HE ADDITIONAL OR RELATED HEALTH -CARE PROCEDURE IS NOT
450		-	EXPERIMENTAL OR INVESTIGATIONAL
451		-	;
452		-	PAGE 10-HOUSE BILL 24-1149 (D) AFTER COMPLETING THE ADDITIONAL OR RELATED HEALTH -CARE
453		-	PROCEDURE AND BEFORE SUBMITTING A CLAIM FOR PAYMENT
454		-	, THE PROVIDER
455		-	NOTIFIES THE CARRIER OR ORGANIZATION THAT THE PROVIDER PERFORMED
456		-	THE ADDITIONAL OR RELATED HEALTH
457		-	-CARE PROCEDURE AND INCLUDES IN
458		-	THE NOTICE THE INFORMATION REQUIRED UNDER THE CARRIER
459		-	'S OR
460		-	ORGANIZATION
461		-	'S CURRENT PRIOR AUTHORIZATION REQUIREMENTS POSTED
462		-	IN ACCORDANCE WITH SUBSECTION
463		-	(2)(a)(I) OF THIS SECTION; AND
464		-	(E) THE PROVIDER IS COMPLIANT WITH THE CARRIER 'S OR
465		-	ORGANIZATION
466		-	'S POST-SERVICE CLAIMS PROCESS, INCLUDING SUBMISSION OF
467		-	THE CLAIM WITHIN THE CARRIER
468		-	'S OR ORGANIZATION'S REQUIRED TIMELINE
469		-	FOR CLAIMS SUBMISSIONS
470		-	.
471		-	(II) W
472		-	HEN A PROVIDER PROVIDES AN ADDITIONAL OR A RELATED
473		-	HEALTH
474		-	-CARE PROCEDURE AS DESCRIBED IN THIS SUBSECTION (4)(c), THE
475		-	CARRIER OR ORGANIZATION SHALL NOT DENY THE CLAIM FOR THE INITIAL
476		-	SURGICAL PROCEDURE FOR WHICH THE CARRIER OR ORGANIZATION
477		-	APPROVED A PRIOR AUTHORIZATION REQUEST ON THE BASIS THAT THE
478		-	PROVIDER PROVIDED THE ADDITIONAL OR RELATED HEALTH
479		-	-CARE
480		-	PROCEDURE
481		-	.
482		-	(5) Duration of approval. (a) Upon approval by the carrier or
483		-	organization, a prior authorization is valid for at least one hundred eighty
484		-	days CALENDAR YEAR after the date of approval and continues for the
485		-	duration of the authorized course of treatment. Except as provided in
486		-	subsection (5)(b) of this section, once approved, a carrier or
487		-	AN organization
488		-	shall not retroactively deny the prior authorization request for a health-care
489		-	service.
490		-	(6) Rules - enforcement. (a) The commissioner may adopt rules as
491		-	necessary to implement this section.
492		-	(b) T
493		-	HE COMMISSIONER MAY ENFORCE THE REQUIREMENTS OF THIS
494		-	SECTION AND IMPOSE A PENALTY OR OTHER REMEDY AGAINST A PERSON
495		-	THAT VIOLATES THIS SECTION
496		-	.
497		-	(7) Definitions. As used in this section:
498		-	(e) "Private utilization review organization" or "organization" has
499		-	the same meaning as set forth MEANS A PRIVATE UTILIZATION REVIEW
500		-	PAGE 11-HOUSE BILL 24-1149 ORGANIZATION, AS DEFINED in section 10-16-112 (1)(a), THAT HAS A
501		-	CONTRACT WITH AND PERFORMS PRIOR AUTHORIZATION ON BEHALF OF A
502		-	CARRIER
503		-	.
504		-	SECTION 3. In Colorado Revised Statutes, 10-16-124.5, amend
505		-	(2)(a)(II)(A), (2)(c)(II)(A), (3)(a) introductory portion, (3)(a)(I), (3)(a)(VI),
506		-	(3)(b) introductory portion, (5), and (6); repeal (3)(a)(II) and (4); and add
507		-	(3.3), (3.5), (5.5), and (6.5) as follows:
508		-	10-16-124.5. Prior authorization form - drug benefits - rules of
509		-	commissioner - definitions - repeal. (2) (a) Except as provided in
510		-	subsection (2)(b) or (2)(c) of this section, a prior authorization request is
511		-	deemed granted if a carrier or pharmacy benefit management firm fails to:
512		-	(II) For prior authorization requests submitted electronically:
513		-	(A) Notify the prescribing provider, within two business days after
514		-	receipt of the request, that the request is approved, denied, or incomplete,
515		-	and if incomplete, indicate the specific additional information, consistent
516		-	with criteria posted pursuant to subparagraph (II) of paragraph (a) of
517		-	subsection (3) SUBSECTION (3.5)(a) of this section, that is required to
518		-	process the request; or
519		-	(c) For nonurgent prior authorization requests related to a covered
520		-	person's HIV prescription drug coverage, the prior authorization request is
521		-	deemed granted if a carrier or pharmacy benefit management firm fails to:
522		-	(II) For prior authorization requests submitted electronically:
523		-	(A) Notify the prescribing provider within one business day after
524		-	receipt of the request that the request is approved, denied, or incomplete,
525		-	and if incomplete, indicate the specific additional information, consistent
526		-	with criteria posted pursuant to subsection (3)(a)(II)
527		-	SUBSECTION (3.5)(a)
528		-	of this section, that is required to process the request; or
529		-	(3) (a) On or before July 31, 2014, The commissioner shall develop,
530		-	by rule, a uniform prior authorization process that:
531		-	(I) Is made available electronically by the carrier or pharmacy
532		-	benefit management firm, but that does not require the prescribing provider
533		-	PAGE 12-HOUSE BILL 24-1149 to submit a prior authorization request electronically, AND SATISFIES THE
534		-	REQUIREMENTS OF SUBSECTION
535		-	(3.3) OF THIS SECTION;
536		-	(II) Requires each carrier and pharmacy benefit management firmto make the following available and accessible in a centralized location on
537		-	its website:
538		-	(A) Its prior authorization requirements and restrictions, including
539		-	a list of drugs that require prior authorization;
540		-	(B) Written clinical criteria that are easily understandable to the
541		-	prescribing provider and that include the clinical criteria for reauthorization
542		-	of a previously approved drug after the prior authorization period has
543		-	expired; and
544		-	(C) The standard form for submitting requests;
545		-	(VI) Requires carriers and pharmacy benefit management firms,
546		-	when notifying a prescribing provider of its decision to deny a prior
547		-	authorization request, to include
548		-	THE INFORMATION REQUIRED BY SECTION
549		-	10-16-112.5 (3)(c)(II) AND a notice that the covered person has a right to
550		-	appeal the adverse determination pursuant to sections 10-16-113 and
551		-	10-16-113.5.
552		-	(b) In developing the uniform prior authorization process, the
553		-	commissioner shall take into consideration the recommendations, if any, of
554		-	the work group established pursuant to subsection (4) of this section and the
555		-	following:
556		-	(3.3) S
557		-	TARTING JANUARY 1, 2027, IF A PROVIDER SUBMITS A PRIOR
558		-	AUTHORIZATION REQUEST TO A CARRIER OR
559		-	PBM THROUGH A SECURE
560		-	ELECTRONIC TRANSMISSION SYSTEM THE CARRIER OR
561		-	PBM USES THAT
562		-	COMPLIES WITH THE MOST RECENT VERSION OF THE
563		-	NATIONAL COUNCIL FOR
564		-	PRESCRIPTION DRUG PROGRAMS SCRIPT STANDARD, OR ITS SUCCESSOR
565		-	STANDARD
566		-	, AND 21 CFR 1311, THE CARRIER OR PBM SHALL ACCEPT AND
567		-	RESPOND TO THE REQUEST THROUGH THE SECURE ELECTRONIC
568		-	TRANSMISSION SYSTEM
569		-	.
570		-	(3.5) (a) O
571		-	N AND AFTER JANUARY 1, 2026, A CARRIER SHALL POST ON
572		-	THE CARRIER
573		-	'S PUBLIC-FACING WEBSITE, IN A READILY ACCESSIBLE ,
574		-	PAGE 13-HOUSE BILL 24-1149 STANDARDIZED, SEARCHABLE FORMAT , PRIOR AUTHORIZATION
575		-	REQUIREMENTS AS APPLICABLE TO THE PRESCRIPTION DRUG FORMULARY FOR
576		-	EACH HEALTH BENEFIT PLAN THE CARRIER OFFERS
577		-	, INCLUDING THE
578		-	FOLLOWING INFORMATION
579		-	:
580		-	(I) T
581		-	HE CARRIER'S PRIOR AUTHORIZATION REQUIREMENTS AND
582		-	RESTRICTIONS
583		-	, INCLUDING A LIST OF DRUGS THAT REQUIRE PRIOR
584		-	AUTHORIZATION
585		-	;
586		-	(II) W
587		-	RITTEN CLINICAL CRITERIA THAT ARE EASILY
588		-	UNDERSTANDABLE TO THE PRESCRIBING PROVIDER AND THAT INCLUDE THE
589		-	CLINICAL CRITERIA FOR REAUTHORIZATION OF A PREVIOUSLY APPROVED
590		-	DRUG AFTER THE PRIOR AUTHORIZATION PERIOD HAS EXPIRED
591		-	;
592		-	(III) T
593		-	HE STANDARD FORM FOR SUBMITTING PRIOR AUTHORIZATION
594		-	REQUESTS
595		-	;
596		-	(IV) T
597		-	HE HEALTH BENEFIT PLAN TO WHICH THE FORMULARY APPLIES ;
598		-	(V) E
599		-	ACH PRESCRIPTION DRUG THAT IS COVERED UNDER THE HEALTH
600		-	BENEFIT PLAN
601		-	, INCLUDING BOTH GENERIC AND BRAND -NAME VERSIONS OF
602		-	A PRESCRIPTION DRUG
603		-	;
604		-	(VI) A
605		-	NY PRESCRIPTION DRUGS ON THE FORMULARY THAT ARE
606		-	PREFERRED OVER OTHER PRESCRIPTION DRUGS OR ANY ALTERNATIVE
607		-	PRESCRIPTION DRUGS THAT DO NOT REQUIRE PRIOR AUTHORIZATION
608		-	;
609		-	(VII) A
610		-	NY EXCLUSIONS FROM OR RESTRICTIONS ON COVERAGE ,
611		-	INCLUDING:
612		-	(A) A
613		-	NY TIERING STRUCTURE , INCLUDING COPAYMENT AND
614		-	COINSURANCE REQUIREMENTS
615		-	;
616		-	(B) P
617		-	RIOR AUTHORIZATION, STEP THERAPY, AND OTHER UTILIZATION
618		-	MANAGEMENT CONTROLS
619		-	;
620		-	(C) Q
621		-	UANTITY LIMITS; AND
622		-	(D) WHETHER ACCESS IS DEPENDENT UPON THE LOCATION WHERE A
623		-	PRESCRIPTION DRUG IS OBTAINED OR ADMINISTERED
624		-	; AND
625		-	PAGE 14-HOUSE BILL 24-1149 (VIII) THE APPEAL PROCESS FOR A DENIAL OF COVERAGE OR
626		-	ADVERSE DETERMINATION FOR AN ITEM OR SERVICE FOR A PRESCRIPTION
627		-	DRUG
628		-	.
629		-	(b) T
630		-	HE COMMISSIONER SHALL ADOPT RULES AS NECESSARY TO
631		-	IMPLEMENT THIS SUBSECTION
632		-	(3.5).
633		-	(4) (a) Within thirty days after May 15, 2013, the commissioner
634		-	shall establish a work group comprised of representatives of:
635		-	(I) The department of regulatory agencies;
636		-	(II) Local and national carriers;
637		-	(III) Captive and noncaptive pharmacy benefit management firms;
638		-	(IV) Providers, including hospitals, physicians, advanced practice
639		-	registered nurses with prescriptive authority, and pharmacists;
640		-	(V) Drug manufacturers;
641		-	(VI) Medical practice managers;
642		-	(VII) Consumers; and
643		-	(VIII) Other stakeholders deemed appropriate by the commissioner.
644		-	(b) The work group shall assist the commissioner in developing the
645		-	prior authorization process and shall make recommendations to the
646		-	commissioner on the items set forth in paragraph (b) of subsection (3) of
647		-	this section. The work group shall report its recommendations to the
648		-	commissioner no later than six months after the commissioner appoints the
649		-	work group members. Regardless of whether the work group submits
650		-	recommendations to the commissioner, the commissioner shall not delay or
651		-	extend the deadline for the adoption of rules creating the prior authorization
652		-	process as specified in paragraph (a) of subsection (3) of this section.
653		-	(5) (a) Notwithstanding any other provision of law, on and after
654		-	January 1, 2015 AND EXCEPT AS PROVIDED IN SUBSECTIONS (5)(b) AND (5.5)
655		-	OF THIS SECTION, every prescribing provider shall use the prior authorization
656		-	PAGE 15-HOUSE BILL 24-1149 process developed pursuant to subsection (3) of this section to request prior
657		-	authorization for coverage of drug benefits, and every carrier and pharmacy
658		-	benefit management firm shall use that process for prior authorization for
659		-	drug benefits.
660		-	(b) (I) A
661		-	CARRIER OR PBM THAT PROVIDES DRUG BENEFITS UNDER
662		-	A HEALTH BENEFIT PLAN SHALL NOT IMPOSE PRIOR AUTHORIZATION
663		-	REQUIREMENTS UNDER THE HEALTH BENEFIT PLAN MORE THAN ONCE EVERY
664		-	THREE YEARS FOR A DRUG THAT IS APPROVED BY THE
665		-	FDA AND THAT IS A
666		-	CHRONIC MAINTENANCE DRUG IF THE CARRIER OR
667		-	PBM HAS PREVIOUSLY
668		-	APPROVED A PRIOR AUTHORIZATION FOR THE COVERED PERSON FOR USE OF
669		-	THE CHRONIC MAINTENANCE DRUG
670		-	.
671		-	(II) T
672		-	HIS SUBSECTION (5)(b) DOES NOT APPLY IF:
673		-	(A) T
674		-	HERE IS EVIDENCE THAT THE AUTHORIZATION WAS OBTAINED
675		-	FROM THE CARRIER OR
676		-	PBM BASED ON FRAUD OR MISREPRESENTATION ;
677		-	(B) F
678		-	INAL ACTION BY THE FDA OR OTHER REGULATORY AGENCIES ,
679		-	OR THE MANUFACTURER, REMOVES THE CHRONIC MAINTENANCE DRUG FROM
680		-	THE MARKET
681		-	, LIMITS ITS USE IN A MANNER THAT AFFECTS THE
682		-	AUTHORIZATION
683		-	, OR COMMUNICATES A PATIENT SAFETY ISSUE THAT WOULD
684		-	AFFECT THE AUTHORIZATION ALONE OR IN COMBINATION WITH OTHER
685		-	AUTHORIZATIONS
686		-	;
	677	+	PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF26
	678	+	THIS SECTION:27
	679	+	1149
	680	+	-21- (I) MUST NOT REQUIRE QUALIFIED PROVIDERS TO REQUEST1
	681	+	PARTICIPATION IN THE PROGRAM; AND2
	682	+	(II) M
	683	+	AY INCLUDE LIMITING THE USE OF PRIOR AUTHORIZATION TO3
	684	+	PROVIDERS WHOSE PRESCRIBING OR ORDERING PATTERNS DIFFER4
	685	+	SIGNIFICANTLY FROM THE PATTERNS OF THEIR PEERS AFTER ADJUSTING5
	686	+	FOR PATIENT MIX AND OTHER RELEVANT FACTORS AND IN ORDER TO6
	687	+	PRESENT THOSE PROVIDERS WITH OPPORTUNITIES FOR IMPROVEMENT IN7
	688	+	ADHERENCE TO THE CARRIER'S OR ORGANIZATION'S PRIOR AUTHORIZATION8
	689	+	REQUIREMENTS.9
687	690		(c) A
688		-	GENERIC EQUIVALENT OR DRUG THAT IS BIOSIMILAR , AS
689		-	DEFINED IN
690		-	42 U.S.C. SEC. 262 (i)(2), TO THE PRESCRIBED CHRONIC
691		-	MAINTENANCE DRUG IS ADDED TO THE CARRIER
692		-	'S OR PBM'S DRUG
693		-	FORMULARY
694		-	; OR
695		-	(D) THE WHOLESALE ACQUISITION COST OF THE CHRONIC
696		-	MAINTENANCE DRUG EXCEEDS A DOLLAR AMOUNT AS ESTABLISHED BY THE
697		-	COMMISSIONER BY RULE
698		-	, WHICH AMOUNT MUST BE NO LESS THAN THIRTY
699		-	THOUSAND DOLLARS FOR A TWELVE
700		-	-MONTH SUPPLY OR FOR A COURSE OF
701		-	TREATMENT THAT IS LESS THAN TWELVE MONTHS IN DURATION
702		-	.
	691	+	T LEAST ANNUALLY, A CARRIER OR PBM SHALL:10
	692	+	(I) R
	693	+	EEXAMINE A PROVIDER 'S PRESCRIBING OR ORDERING11
	694	+	PATTERNS;12
	695	+	(II) R
	696	+	EEVALUATE THE PROVIDER'S STATUS FOR EXEMPTION FROM13
	697	+	PRIOR AUTHORIZATION REQUIREMENTS OR FOR INCLUSION IN THE14
	698	+	PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF THIS15
	699	+	SECTION; AND16
703	700		(III) N
704		-	OTHING IN THIS SUBSECTION (5)(b) REQUIRES A CARRIER OR
705		-	PBM TO PAY FOR A BENEFIT:
706		-	(A) T
707		-	HAT IS NOT A COVERED BENEFIT UNDER THE HEALTH BENEFIT
708		-	PAGE 16-HOUSE BILL 24-1149 PLAN; OR
709		-	(B) IF THE PATIENT IS NO LONGER A COVERED PERSON UNDER THE
710		-	HEALTH BENEFIT PLAN ON THE DATE THE CHRONIC MAINTENANCE DRUG WAS
711		-	PRESCRIBED
712		-	, DISPENSED, ADMINISTERED, OR DELIVERED.
713		-	(IV) A
714		-	S USED IN THIS SUBSECTION (5)(b), "CHRONIC MAINTENANCE
715		-	DRUG
716		-	" HAS THE MEANING SET FORTH IN SECTION 12-280-103 (9.5).
717		-	(5.5) (a) N
718		-	O LATER THAN JANUARY 1, 2026, A CARRIER OR PBM
719		-	SHALL ADOPT A PROGRAM, DEVELOPED IN CONSULTATION WITH PROVIDERS
720		-	PARTICIPATING WITH THE CARRIER
721		-	, TO ELIMINATE OR SUBSTANTIALLY
722		-	MODIFY PRIOR AUTHORIZATION REQUIREMENTS IN A MANNER THAT REMOVES
723		-	THE ADMINISTRATIVE BURDEN FOR QUALIFIED PROVIDERS
724		-	, AS DEFINED
725		-	UNDER THE PROGRAM
726		-	, AND THEIR PATIENTS FOR CERTAIN PRESCRIPTION
727		-	DRUGS AND RELATED DRUG BENEFITS BASED ON ANY OF THE FOLLOWING
728		-	:
729		-	(I) T
730		-	HE PERFORMANCE OF PROVIDERS WITH RESPECT TO ADHERENCE
731		-	TO NATIONALLY RECOGNIZED
732		-	, EVIDENCE-BASED MEDICAL GUIDELINES ,
733		-	APPROPRIATENESS, EFFICIENCY, AND OTHER QUALITY CRITERIA; AND
734		-	(II) PROVIDER SPECIALTY, EXPERIENCE, OR OTHER OBJECTIVE
735		-	FACTORS
736		-	; EXCEPT THAT ELIGIBILITY FOR THE PROGRAM MUST NOT BE
737		-	LIMITED BY PROVIDER SPECIALTY
738		-	.
739		-	(b) A
740		-	PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF
741		-	THIS SECTION
742		-	:
743		-	(I) M
744		-	UST NOT REQUIRE QUALIFIED PROVIDERS TO REQUEST
745		-	PARTICIPATION IN THE PROGRAM
746		-	; AND
747		-	(II) MAY INCLUDE LIMITING THE USE OF PRIOR AUTHORIZATION TO
748		-	PROVIDERS WHOSE PRESCRIBING OR ORDERING PATTERNS DIFFER
749		-	SIGNIFICANTLY FROM THE PATTERNS OF THEIR PEERS AFTER ADJUSTING FOR
750		-	PATIENT MIX AND OTHER RELEVANT FACTORS AND IN ORDER TO PRESENT
751		-	THOSE PROVIDERS WITH OPPORTUNITIES FOR IMPROVEMENT IN ADHERENCE
752		-	TO THE CARRIER
753		-	'S OR ORGANIZATION 'S PRIOR AUTHORIZATION
754		-	REQUIREMENTS
755		-	.
756		-	(c) A
757		-	T LEAST ANNUALLY, A CARRIER OR PBM SHALL:
758		-	PAGE 17-HOUSE BILL 24-1149 (I) REEXAMINE A PROVIDER'S PRESCRIBING OR ORDERING PATTERNS;
759		-	(II) R
760		-	EEVALUATE THE PROVIDER 'S STATUS FOR EXEMPTION FROM
761		-	PRIOR AUTHORIZATION REQUIREMENTS OR FOR INCLUSION IN THE PROGRAM
762		-	DEVELOPED PURSUANT TO SUBSECTION
763		-	(5.5)(a) OF THIS SECTION; AND
764		-	(III) NOTIFY THE PROVIDER OF THE PROVIDER 'S STATUS FOR
765		-	EXEMPTION OR INCLUSION IN THE PROGRAM
766		-	.
	701	+	OTIFY THE PROVIDER OF THE PROVIDER 'S STATUS FOR17
	702	+	EXEMPTION OR INCLUSION IN THE PROGRAM .18
767	703		(d) A
768		-	PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF
769		-	THIS SECTION MUST INCLUDE PROCEDURES FOR A PROVIDER TO REQUEST
770		-	:
771		-	(I) A
772		-	N EXPEDITED, INFORMAL RESOLUTION OF A CARRIER'S OR PBM'S
773		-	FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE PROGRAM
774		-	; AND
775		-	(II) IF THE MATTER IS NOT RESOLVED THROUGH INFORMAL
776		-	RESOLUTION
777		-	, BINDING ARBITRATION AS SPECIFIED IN SUBSECTION (5.5)(e) OF
778		-	THIS SECTION
779		-	.
780		-	(e) I
781		-	F A PROVIDER REQUESTS BINDING ARBITRATION PURSUANT TO
782		-	THE PROCEDURES A CARRIER OR A
783		-	PBM DEVELOPS UNDER SUBSECTION
784		-	(5.5)(d)(II) OF THIS SECTION, THE FOLLOWING PROVISIONS GOVERN THE
785		-	ARBITRATION PROCEDURE
786		-	:
787		-	(I) T
788		-	HE PROVIDER AND CARRIER OR PBM SHALL JOINTLY SELECT AN
789		-	ARBITRATOR FROM THE LIST OF ARBITRATORS APPROVED PURSUANT TO
790		-	SECTION
791		-	10-16-704 (15)(b). NEITHER THE PROVIDER NOR THE CARRIER OR
792		-	PBM IS REQUIRED TO NOTIFY THE DIVISION OF THE ARBITRATION OR OF THE
793		-	SELECTED ARBITRATOR
794		-	.
795		-	(II) T
796		-	HE SELECTED ARBITRATOR SHALL DETERMINE THE PROVIDER 'S
797		-	ELIGIBILITY TO PARTICIPATE IN THE CARRIER
798		-	'S OR PBM'S PROGRAM BASED
799		-	ON THE PROGRAM CRITERIA DEVELOPED PURSUANT TO SUBSECTION
800		-	(5.5)(a)
801		-	OF THIS SECTION;
802		-	(III) W
803		-	ITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
804		-	ACCEPTS THE MATTER
805		-	, THE PROVIDER AND THE CARRIER OR PBM SHALL
806		-	SUBMIT TO THE ARBITRATOR WRITTEN MATERIALS IN SUPPORT OF THEIR
807		-	RESPECTIVE POSITIONS
808		-	;
809		-	PAGE 18-HOUSE BILL 24-1149 (IV) THE ARBITRATOR MAY RENDER A DECISION BASED ON THE
810		-	WRITTEN MATERIALS SUBMITTED PURSUANT TO SUBSECTION
811		-	(5.5)(e)(III) OF
812		-	THIS SECTION OR MAY SCHEDULE A HEARING
813		-	, LASTING NOT LONGER THAN
814		-	ONE DAY
815		-	, FOR THE PROVIDER AND CARRIER OR PBM TO PRESENT EVIDENCE;
816		-	(V) W
817		-	ITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
818		-	RECEIVES THE WRITTEN MATERIALS OR
819		-	, IF A HEARING IS CONDUCTED, THE
820		-	DATE OF THE HEARING
821		-	, THE ARBITRATOR SHALL ISSUE A WRITTEN DECISION
822		-	STATING WHETHER THE PROVIDER IS ELIGIBLE FOR THE PROGRAM
823		-	; AND
824		-	(VI) IF THE ARBITRATOR OVERTURNS THE CARRIER 'S OR PBM'S
825		-	FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE PROGRAM
826		-	, THE
827		-	CARRIER OR
828		-	PBM SHALL PAY THE ARBITRATOR'S FEES AND COSTS, AND IF
829		-	THE ARBITRATOR AFFIRMS THE CARRIER
830		-	'S OR PBM'S FAILURE OR REFUSAL TO
831		-	INCLUDE THE PROVIDER IN THE PROGRAM
832		-	, THE PROVIDER SHALL PAY THE
833		-	ARBITRATOR
834		-	'S FEES AND COSTS.
835		-	(6) Upon approval by the carrier or pharmacy benefit management
836		-	firm, a prior authorization is valid for at least one hundred eighty days
837		-	CALENDAR YEAR after the date of approval. If, as a result of a change to the
838		-	carrier's formulary, the drug for which the carrier or pharmacy benefit
839		-	management firm has provided prior authorization is removed from the
840		-	formulary or moved to a less preferred tier status, the change in the status
841		-	of the previously approved drug does not affect a covered person who
842		-	received prior authorization before the effective date of the change for the
843		-	remainder of the covered person's plan year. Nothing in this subsection (6)
844		-	limits the ability of a carrier or pharmacy benefit management firm, in
845		-	accordance with the terms of the health benefit plan, to substitute a generic
846		-	drug, with the prescribing provider's approval and patient's consent, for a
847		-	previously approved brand-name drug.
	704	+	PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF19
	705	+	THIS SECTION MUST INCLUDE PROCEDURES FOR A PROVIDER TO REQUEST :20
	706	+	(I) AN EXPEDITED, INFORMAL RESOLUTION OF A CARRIER 'S OR21
	707	+	PBM'
	708	+	S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE PROGRAM ;22
	709	+	AND23 (II) IF THE MATTER IS NOT RESOLVED THROUGH INFORMAL24
	710	+	RESOLUTION, BINDING ARBITRATION AS SPECIFIED IN SUBSECTION (5.5)(e)25
	711	+	OF THIS SECTION.26
	712	+	(e) IF A PROVIDER REQUESTS BINDING ARBITRATION PURSUANT TO27
	713	+	1149
	714	+	-22- THE PROCEDURES A CARRIER OR A PBM DEVELOPS UNDER SUBSECTION1
	715	+	(5.5)(d)(II) OF THIS SECTION, THE FOLLOWING PROVISIONS GOVERN THE2
	716	+	ARBITRATION PROCEDURE:3
	717	+	(I) THE PROVIDER AND CARRIER OR PBM SHALL JOINTLY SELECT4
	718	+	AN ARBITRATOR FROM THE LIST OF ARBITRATORS APPROVED PURSUANT TO5
	719	+	SECTION 10-16-704 (15)(b). NEITHER THE PROVIDER NOR THE CARRIER OR6
	720	+	PBM IS REQUIRED TO NOTIFY THE DIVISION OF THE ARBITRATION OR OF7
	721	+	THE SELECTED ARBITRATOR.8
	722	+	(II) THE SELECTED ARBITRATOR SHALL DETERMINE THE9
	723	+	PROVIDER'S ELIGIBILITY TO PARTICIPATE IN THE CARRIER'S OR PBM'S10
	724	+	PROGRAM BASED ON THE PROGRAM CRITERIA DEVELOPED PURSUANT TO11
	725	+	SUBSECTION (5.5)(a) OF THIS SECTION;12
	726	+	(III) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR13
	727	+	ACCEPTS THE MATTER, THE PROVIDER AND THE CARRIER OR PBM SHALL14
	728	+	SUBMIT TO THE ARBITRATOR WRITTEN MATERIALS IN SUPPORT OF THEIR15
	729	+	RESPECTIVE POSITIONS;16
	730	+	(IV) THE ARBITRATOR MAY RENDER A DECISION BASED ON THE17
	731	+	WRITTEN MATERIALS SUBMITTED PURSUANT TO SUBSECTION (5.5)(e)(III)18
	732	+	OF THIS SECTION OR MAY SCHEDULE A HEARING , LASTING NOT LONGER19
	733	+	THAN ONE DAY, FOR THE PROVIDER AND CARRIER OR PBM TO PRESENT20
	734	+	EVIDENCE;21
	735	+	(V) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR22
	736	+	RECEIVES THE WRITTEN MATERIALS OR, IF A HEARING IS CONDUCTED, THE23
	737	+	DATE OF THE HEARING , THE ARBITRATOR SHALL ISSUE A WRITTEN24
	738	+	DECISION STATING WHETHER THE PROVIDER IS ELIGIBLE FOR THE25
	739	+	PROGRAM; AND26
	740	+	(VI) IF THE ARBITRATOR OVERTURNS THE CARRIER 'S OR PBM'S27
	741	+	1149
	742	+	-23- FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE PROGRAM, THE1
	743	+	CARRIER OR PBM SHALL PAY THE ARBITRATOR'S FEES AND COSTS, AND IF2
	744	+	THE ARBITRATOR AFFIRMS THE CARRIER'S OR PBM'S FAILURE OR REFUSAL3
	745	+	TO INCLUDE THE PROVIDER IN THE PROGRAM, THE PROVIDER SHALL PAY4
	746	+	THE ARBITRATOR'S FEES AND COSTS.5
	747	+	(6) Upon approval by the carrier or pharmacy benefit management6
	748	+	firm, a prior authorization is valid for at least one hundred eighty days7
	749	+	CALENDAR YEAR after the date of approval. If, as a result of a change to8
	750	+	the carrier's formulary, the drug for which the carrier or pharmacy benefit9
	751	+	management firm has provided prior authorization is removed from the10
	752	+	formulary or moved to a less preferred tier status, the change in the status11
	753	+	of the previously approved drug does not affect a covered person who12
	754	+	received prior authorization before the effective date of the change for the13
	755	+	remainder of the covered person's plan year. Nothing in this subsection14
	756	+	(6) limits the ability of a carrier or pharmacy benefit management firm,15
	757	+	in accordance with the terms of the health benefit plan, to substitute a16
	758	+	generic drug, with the prescribing provider's approval and patient's17
	759	+	consent, for a previously approved brand-name drug.18
848	760		(6.5) T
849		-	HE COMMISSIONER MAY ENFORCE THE REQUIREMENTS OF THIS
850		-	SECTION AND IMPOSE A PENALTY OR OTHER REMEDY AGAINST A PERSON
851		-	THAT VIOLATES THIS SECTION
852		-	.
853		-	SECTION 4. Appropriation. (1) For the 2024-25 state fiscal year,
854		-	$36,514 is appropriated to the department of regulatory agencies for use by
855		-	the division of insurance. This appropriation is from the division of
856		-	insurance cash fund created in section 10-1-103 (3)(a)(I), C.R.S. To
857		-	implement this act, the division may use this appropriation as follows:
858		-	PAGE 19-HOUSE BILL 24-1149 (a) $29,332 for personal services, which amount is based on an
859		-	assumption that the division will require an additional 0.4 FTE; and
860		-	(b) $7,182 for operating expenses.
861		-	SECTION 5. Act subject to petition - effective date -
862		-	applicability. (1) This act takes effect at 12:01 a.m. on the day following
863		-	the expiration of the ninety-day period after final adjournment of the
864		-	general assembly; except that, if a referendum petition is filed pursuant to
865		-	section 1 (3) of article V of the state constitution against this act or an item,
866		-	section, or part of this act within such period, then the act, item, section, or
867		-	part will not take effect unless approved by the people at the general
868		-	PAGE 20-HOUSE BILL 24-1149 election to be held in November 2024 and, in such case, will take effect on
869		-	the date of the official declaration of the vote thereon by the governor.
870		-	(2) This act applies to conduct occurring on or after January 1, 2026.
871		-	____________________________ ____________________________
872		-	Julie McCluskie Steve Fenberg
873		-	SPEAKER OF THE HOUSE PRESIDENT OF
874		-	OF REPRESENTATIVES THE SENATE
875		-	____________________________ ____________________________
876		-	Robin Jones Cindi L. Markwell
877		-	CHIEF CLERK OF THE HOUSE SECRETARY OF
878		-	OF REPRESENTATIVES THE SENATE
879		-	APPROVED________________________________________
880		-	(Date and Time)
881		-	_________________________________________
882		-	Jared S. Polis
883		-	GOVERNOR OF THE STATE OF COLORADO
884		-	PAGE 21-HOUSE BILL 24-1149
	761	+	HE COMMISSIONER MAY ENFORCE THE REQUIREMENTS OF19
	762	+	THIS SECTION AND IMPOSE A PENALTY OR OTHER REMEDY AGAINST A20
	763	+	PERSON THAT VIOLATES THIS SECTION.21
	764	+	22
	765	+	SECTION 4. Appropriation. (1) For the 2024-25 state fiscal23
	766	+	year, $36,514 is appropriated to the department of regulatory agencies for24
	767	+	use by the division of insurance. This appropriation is from the division25
	768	+	of insurance cash fund created in section 10-1-103 (3)(a)(I), C.R.S. To26
	769	+	implement this act, the division may use this appropriation as follows:27
	770	+	1149
	771	+	-24- (a) $29,332 for personal services, which amount is based on an1
	772	+	assumption that the division will require an additional 0.4 FTE; and2
	773	+	(b) $7,182 for operating expenses.3
	774	+	SECTION 5. Act subject to petition - effective date -4
	775	+	applicability. (1) This act takes effect at 12:01 a.m. on the day following5
	776	+	the expiration of the ninety-day period after final adjournment of the6
	777	+	general assembly; except that, if a referendum petition is filed pursuant7
	778	+	to section 1 (3) of article V of the state constitution against this act or an8
	779	+	item, section, or part of this act within such period, then the act, item,9
	780	+	section, or part will not take effect unless approved by the people at the10
	781	+	general election to be held in November 2024 and, in such case, will take11
	782	+	effect on the date of the official declaration of the vote thereon by the12
	783	+	governor.13
	784	+	(2) This act applies to conduct occurring on or after January 1,14
	785	+	2026.15
	786	+	1149
	787	+	-25-