2023 Colorado Revised Statutes › Title 12 - PROFESSIONS AND OCCUPATIONS (§§ 12-1-101 — 12-315-310) › DIVISION OF PROFESSIONS AND OCCUPATIONS (§§ 12-20-101 — 12-30-209) › Article 30 - PROVISIONS APPLICABLE TO HEALTH-CARE PROFESSIONS AND OCCUPATIONS (§§ 12-30-101 — 12-30-209) › Part 1 - MISCELLANEOUS PROVISIONS APPLICABLE TO HEALTH-CARE PROFESSIONS AND OCCUPATIONS (§§ 12-30-101 — 12-30-124) › Section 12-30-113 - Out-of-network health-care providers - out-of-network services - billing - payment - deceptive trade practice

(1)
If an out-of-network health-care provider provides emergency services or covered nonemergency services to a covered person at an in-network facility, the out-of-network provider shall:
(a)
Submit a claim for the entire cost of the services to the covered person's carrier; and
(b)
Not bill or collect payment from a covered person for any outstanding balance for covered services not paid by the carrier, except for the applicable in-network coinsurance, deductible, or copayment amount required to be paid by the covered person.
(2)
(a)
If an out-of-network health-care provider provides covered nonemergency services at an in-network facility or emergency services at an out-of-network or in-network facility and the health-care provider receives payment from the covered person for services for which the covered person is not responsible pursuant to section
10-16-704 (3)(b)
or (5.5), the health-care provider shall reimburse the covered person within sixty calendar days after the date that the overpayment was reported to the provider.
(b)
An out-of-network health-care provider that fails to reimburse a covered person as required by subsection (2)(a) of this section for an overpayment shall pay interest on the overpayment at the rate of ten percent per annum beginning on the date the provider received the notice of the overpayment. The covered person is not required to request the accrued interest from the out-of-network health-care provider in order to receive interest with the reimbursement amount.
(3)
An out-of-network health-care provider shall provide a covered person a written estimate of the amount for which the covered person may be responsible for covered nonemergency services within three business days after a request from the covered person.
(4)
(a)
An out-of-network health-care provider must send a claim for a covered service to the carrier within one hundred eighty days after the receipt of insurance information in order to receive reimbursement as specified in this subsection (4)(a). The reimbursement rate is the greater of:
(I)
One hundred ten percent of the carrier's median in-network rate of reimbursement for that service provided in the same geographic area; or
(II)
The sixtieth percentile of the in-network rate of reimbursement for the same service in the same geographic area for the prior year based on claims data from the all-payer health claims database described in section
25.5-1-204
.
(b)
If the out-of-network health-care provider submits a claim for covered services after the one-hundred-eighty-day period specified in subsection (4)(a) of this section, the carrier shall reimburse the health-care provider one hundred twenty-five percent of the medicare reimbursement rate for the same services in the same geographic area.
(c)
The health-care provider shall not bill a covered person any outstanding balance for a covered service not paid for by the carrier, except for any coinsurance, deductible, or copayment amount required to be paid by the covered person.
(5)
A health-care provider may initiate arbitration pursuant to section
10-16-704 (15)
if the health-care provider believes the payment made pursuant to subsection (4) of this section is not sufficient.
(6)
A violation of this section is a deceptive trade practice pursuant to section
6-1-105 (1)(xxx)
.
Amended by 2023 Ch. 152,§ 10, eff. 5/4/2023.
Amended by 2020 Ch. 21, § 2, eff. 3/11/2020.
Added by 2019 Ch. 171, § 8, eff. 1/1/2020.
(1) Section 10 of chapter 171 (HB 19-1174), Session Laws of Colorado 2019, provides that the act adding this section:
(a) Applies to health care services provided on or after January 1, 2020; and
(b) Takes effect January 1, 2020, only if HB 19-1172 becomes law. HB 19-1172 became law and took effect October 1, 2019.
(1) For definitions applicable to this section, see § 12-30-112 . (2) For the legislative declaration in SB 20-043, see section 1 of chapter 78, Session Laws of Colorado 2020.