In Colorado the carrier must ask the state who will review its denial

The carrier asks; the Division answers

Most states describe external review from the patient's side. Colorado's statute describes it from the carrier's: once a request comes in, the carrier must contact the Division of Insurance, and the Division or its contractor tells the carrier the name of the independent external review entity that will handle the case. The insurer is a party to the review, not the organiser of it.

• The Division — not the carrier — names the reviewing entity.
• The reviewer is an expert reviewer independent of the plan.
• Denials turning on medical necessity are the core of what is eligible.

Four months from the notice

The statutory window is four months: an individual requesting an independent external review must make the request within four months after receiving notification of the denial. The clock runs from the notice, so the date on the letter is the date that matters — not the date the claim was denied internally, and not the date you got around to reading it.

How to start one

1. 1

   Finish the carrier's internal appeal

   External review follows the plan's own appeal process, except where the case is urgent enough to run in parallel.

2. 2

   Request the external review from the carrier

   The request goes in, and the statute then puts the burden on the carrier to contact the Division for an assignment.

3. 3

   Send the clinical record

   The expert reviewer decides on what is in front of them. Include the documentation that shows the service met the criterion the plan applied.

4. 4

   Ask the Division if anything stalls

   The Division of Insurance Consumer Services team takes questions about external-review requests at 303-894-7490 or [email protected].

Speed, and who pays

• Standard review: decided within 45 calendar days of receipt of the request.
• Expedited review: within 72 hours, with written confirmation inside 48 hours where the decision was first given orally.
• Cost: the carrier pays for the independent external review. There is no bill to the patient or the practice.

Binding — on both sides

Colorado is explicit that the determination of the expert reviewer binds the carrier and the individual who requested the review. That cuts both ways and is worth understanding before filing: an overturn obliges the plan to cover the service, and an upheld denial closes this avenue rather than opening another. It is a reason to file the complete record the first time rather than holding material back.

Prior authorization: 180 days, published rules, and an exemption at 80%

Colorado moved on the front end in 2019 with HB19-1211, effective 08/02/2019, and the provisions are the kind a practice can hold a carrier to:

• An approved prior authorization is valid for at least 180 days, and continues for the duration of the authorized course of treatment.
• Carriers must publish and keep current their prior-authorization requirements and restrictions — an unpublished criterion is contestable as such.
• A provider with an 80% approval rate on prior-authorization requests over the previous 12 months may qualify for exemption from prior authorization altogether.

For Colorado practices

Two habits pay off here. Diary the four months from the date printed on the denial notice, because that is the date the statute keys to. And treat the submission as final: with a determination that binds both parties, an incomplete file is not a first draft, it is the whole case. Where the denial turns on medical necessity, the strongest submissions map the documented findings and prior treatment onto the specific criterion the carrier cited.