(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:
Submit a claim for the entire cost of the services to the covered person's carrier; and
Not bill or collect payment from a covered person for any outstanding balance forcovered 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.
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.
(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:
One hundred ten percent of the carrier's median in-network rate of reimbursement forthat service provided in the same geographic area; or
The sixtieth percentile of the in-network rate of reimbursement for the same servicein 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.
If the out-of-network health care provider submits a claim for covered services afterthe 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.
The health care provider shall not bill a covered person any outstanding balance for acovered 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.
Source: L. 2019: Entire section added, (HB 19-1174), ch. 171, p. 1997, § 8, effective January 1, 2020. L. 2020: (4)(a) amended, (SB 20-043), ch. 21, p. 78, § 2, effective March 11.
Cross references: (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.