(I) The independent external review entity shall ensure that cases are reviewed by expert reviewers knowledgeable about the recommended treatment or service through the expert reviewers' actual, current clinical experience and who have appropriate expertise in the same or similar specialties as would typically manage the case being reviewed.
(II) The independent external review entity shall ensure that the decision is based upon a case review that includes a review of the medical records of the individual requesting an independent external review and a review of relevant medical and scientific evidence.
(III) The independent external review entity shall have a quality assurance procedure that ensures the timeliness and quality of the reviews conducted pursuant to this section, the qualifications and independence of the expert reviewers, and the confidentiality of medical records and review materials.
(IV) The independent external review entity shall maintain patient confidentiality pursuant to Colorado and federal law.
Source: L. 99: Entire section added, p. 1048, § 2, effective June 1, 2000. L. 2005: (2)(a)(I)(A) amended, p. 805, § 3, effective January 1, 2006. L. 2013: Entire section amended, (HB 13-1266), ch. 217, p. 961, § 20, effective May 13. L. 2016: (2)(f) amended, (SB 16-189), ch. 210, p. 756, § 15, effective June 6.
Structure Colorado Code
Article 16 - Health-Care Coverage
§ 10-16-103. Proposal of Mandatory Health- Care Coverage Provisions
§ 10-16-103.4. Essential Health Benefits - Requirements - Rules
§ 10-16-103.5. Payment of Premiums - Required Term in Contract - Rules - Definition
§ 10-16-104. Mandatory Coverage Provisions - Definitions - Rules
§ 10-16-104.2. Coverage for Contraception - Definitions
§ 10-16-104.6. Off-Label Use of Cancer Drugs
§ 10-16-104.7. Substance Use Disorders - Court-Ordered Treatment Coverage
§ 10-16-104.9. Geographic Areas for Small Employers
§ 10-16-105.2. Small Employer Health Insurance Availability Program
§ 10-16-105.3. Health Benefit Plans - Not Prohibited
§ 10-16-105.7. Health Benefit Plan Open Enrollment Periods - Special Enrollment Periods - Rules
§ 10-16-106. Group Replacement - Extension of Benefits
§ 10-16-106.3. Uniform Claims - Billing Codes - Electronic Claim Forms
§ 10-16-106.5. Prompt Payment of Claims - Legislative Declaration - Rules
§ 10-16-106.7. Assignment of Health Insurance Benefits
§ 10-16-107. Rate Filing Regulation - Benefits Ratio - Rules
§ 10-16-107.1. False or Misleading Information - Penalties
§ 10-16-107.2. Filing of Health Policies - Rules
§ 10-16-107.3. Health Insurance Policies - Plain Language Required - Rules
§ 10-16-107.5. Uniform Application Form - Use by All Carriers - Rules
§ 10-16-107.7. Nondiscrimination Against Providers
§ 10-16-108. Continuation Privileges
§ 10-16-108.5. Fair Marketing Standards - Rules
§ 10-16-110. Fees Paid by Health Coverage Entities
§ 10-16-111. Annual Statements and Reports - Rules
§ 10-16-112. Private Utilization Review - Health-Care Coverage Entity Responsibility - Definitions
§ 10-16-113. Procedure for Denial of Benefits - Internal Review - Rules - Definitions
§ 10-16-113.7. Reporting the Denial of Benefits to Division
§ 10-16-118. Prohibition Against Preexisting Condition Exclusions
§ 10-16-121. Required Contract Provisions in Contracts Between Carriers and Providers - Definitions
§ 10-16-122. Access to Prescription Drugs
§ 10-16-122.5. Pharmacy Benefit Manager - Audit of Pharmacies - Time Limits on On-Site Audits
§ 10-16-122.9. Prescription Drug Benefits - Real-Time Access to Benefit Information - Definitions
§ 10-16-123. Telehealth - Definitions
§ 10-16-124. Prescription Information Cards - Legislative Declaration
§ 10-16-124.5. Prior Authorization Form - Drug Benefits - Rules of Commissioner - Definitions
§ 10-16-124.7. Opioid Analgesics With Abuse-Deterrent Properties - Study - Definitions
§ 10-16-125. Reimbursement to Nurses
§ 10-16-126. Fee-for-Service Dental Plans
§ 10-16-127. Coinsurance and Deductibles
§ 10-16-128. Annual Report to General Assembly
§ 10-16-129. Health Savings Accounts
§ 10-16-130. Disclosure of Rate Increases to Public Entities - Legislative Declaration - Definitions
§ 10-16-134. Health-Care Transparency - Information Required - Website - Definition
§ 10-16-135. Health Benefit Plan Information Cards - Rules - Standardization - Contents
§ 10-16-137. Policy Forms - Explanation of Benefits - Standardization of Forms - Rules
§ 10-16-138. Pathology Services - Direct Billing Required
§ 10-16-139. Access to Care - Rules - Definitions
§ 10-16-140. Grace Periods - Premium Payments - Rules
§ 10-16-142. Physical Rehabilitation Services - Copayments and Coinsurance - Research
§ 10-16-143.5. Pharmacy Reimbursement - Substance Use Disorders - Injections - Patient Counseling
§ 10-16-144. Health-Care Services Provided by Pharmacists
§ 10-16-145. Step Therapy - Prohibited - Definition
§ 10-16-145.5. Step Therapy Prohibited - Stage Four Advanced Metastatic Cancer - Definition
§ 10-16-146. Periodic Updates to Provider Directory
§ 10-16-147. Parity Reporting - Commissioner - Carriers - Rules - Examination of Complaints
§ 10-16-148. Medication-Assisted Treatment - Limitations on Carriers - Rules - Definition
§ 10-16-149. Commissioner Report - Parity Effects on Premiums - Repeal
§ 10-16-151. Cost Sharing in Prescription Insulin Drugs - Limits - Definition - Rules
§ 10-16-153. Coverage for Opiate Antagonists Provided by a Hospital - Definition