C.R.S. Section 10-4-642
Prompt payment of direct benefits

  • legislative declaration
  • definitions

(1)

The general assembly finds, determines, and declares that patients and health-care providers are entitled to receive reimbursements from auto insurance entities in a timely manner. Therefore, it is in the interest of the citizens of Colorado that reasonable standards be imposed for the timely payment of claims.

(2)

As used in this section, unless the context otherwise requires:

(a)

“Claim” means a claim for payment of medical payments coverage benefits in accordance with the insurer’s policy.

(b)

“Claimant” means a policyholder, insured, or injured person entitled to medical payments benefits as a result of a motor vehicle accident or a provider with the proper assignment of benefits.

(c)

“Clean claim” means:

(I)

A claim where there is no additional information needed by the insurer to accept or deny the claim. A claim requiring additional information shall not be considered a clean claim and shall be paid, denied, or settled as set forth in paragraph (b) of subsection (6) of this section.

(II)

A claim form that is submitted with, or after submission of, a properly executed application form for benefits currently used by the insurer by the policyholder, insured, or injured person entitled to benefits.

(3)

The commissioner may, in consultation with interested parties, including health-care providers, adopt a uniform application form for medical payments benefits or a uniform claim form or both a uniform application and uniform claim form. For a uniform claim form or a uniform application form having elements provided by a health-care provider, the commissioner shall consider the uniform claim forms and elements adopted for health insurance pursuant to section 10-16-106.3. If the commissioner determines that new elements are required to establish that an injury or benefit requested is the result of a motor vehicle accident, the new elements may be listed in a separate uniform application form.

(4)

Intentionally left blank —Ed.

(a)

A claimant may submit a claim:

(I)

By United States mail, first class, or by overnight delivery service;

(II)

Electronically, if the insurer accepts claims electronically, to the location designated by the insurer;

(III)

By facsimile to the location designated by the insurer; or

(IV)

By hand delivery to the location designated by the insurer.

(b)

Intentionally left blank —Ed.

(I)

The provider may contact the insurer for the purpose of resubmission of a claim. The insurer shall have a separate facsimile process to receive resubmitted paper claims. A resubmitted claim shall be deemed received on the date of the facsimile transmission acknowledgment.

(II)

If a claim is submitted electronically, it is presumed to have been received by the insurer or the insurer’s clearinghouse, if applicable, on the date of the electronic verification of receipt. If a claim is submitted by facsimile, it is presumed to have been received by the insurer or the insurer’s clearinghouse, if applicable, on the date of the facsimile transmission acknowledgment. If a claim is submitted by mail, it is presumed to have been received by the insurer or the insurer’s clearinghouse, if applicable, three business days after the date of mailing. If a claim is submitted by overnight delivery service or by hand delivery, it is presumed to have been received on the date of delivery.

(c)

The presumptions in paragraph (b) of this subsection (4) may be rebutted by:

(I)

A date stamp on a claim showing the date of receipt. Such date shall be presumed the date of receipt.

(II)

The fact that the insurer’s records maintained in the ordinary course of business do not evidence receipt of a claim. In such case, the claim shall be deemed not to have been received by the insurer.

(d)

An insurer shall maintain claim data that is accessible and retrievable for examination by the commissioner for the current year and for the two immediately preceding years. For each claim, an insurer shall provide a claim number, date of loss, date of auto accident, date of receipt of an application for benefits, date of receipt of a claim, date of payment of a claim, and date of denial or date the claim is closed without payment. An insurer shall detail all material activities relative to a claim. A claim file shall have all material documentation relative to a claim. Each material document within a claim file shall be noted as to date received, date processed, or date sent. Detailed documentation shall be contained in each claim file to permit reconstruction of the insurer’s activities relative to each claim.

(5)

Intentionally left blank —Ed.

(a)

Every insurer shall provide a copy of its claim filing requirements to every insured or provider upon request within fifteen calendar days after the request is received by the insurer.

(b)

Every insurer shall, within fifteen calendar days after receipt of a notification of loss, an application for benefits, or a claim, provide the necessary application or claim forms and instructions so that the claimant can comply with the policy conditions.

(6)

Intentionally left blank —Ed.

(a)

Clean claims shall be paid, denied, or settled within thirty calendar days after receipt by the insurer if submitted electronically and within forty-five calendar days after receipt by the insurer if submitted by any other means.

(b)

If the resolution of a claim requires additional information, the insurer shall, within thirty calendar days after receipt of the claim, give to the claimant a full explanation in writing of what additional information is needed to resolve the claim, including any additional medical or other information related to the claim. The person receiving a request for such additional information shall submit all additional information requested by the insurer within thirty calendar days after receipt of such request. The insurer may deny a claim if a provider receives a request for additional information and fails to timely submit additional information requested under this paragraph (b), subject to the resubmittal of the claim or terms of the policy. If such person has provided all such additional information necessary to resolve the claim, the claim shall be paid, denied, or settled by the insurer within thirty days after receipt of additional information or after the applicable time period set forth in paragraph (c) of this subsection (6).

(c)

Absent fraud, all claims other than clean claims shall be paid, denied, or settled within ninety calendar days after receipt by the insurer; except that the commissioner may adopt rules for the purpose of exempting an insurer from the requirement that the insurer pay, deny, or settle a claim within ninety calendar days in circumstances where the investigation of a claim by the insurer is incomplete or otherwise needs to be continued and for extraordinary or unusual claims with extenuating circumstances as determined by the commissioner. The rules shall require the insurer, within thirty days after the receipt of a claim and every thirty days thereafter, to send to the claimant or the claimant’s representative, and to the health-care provider if applicable, a letter setting forth the reasons why additional time is needed. The insurer that is exempt from the ninety-day time period due to circumstances where an investigation is incomplete or otherwise needs to be continued shall pay, deny, or settle the claim within one hundred eighty days after receipt of the claim. An insurer that is exempt from the ninety-day time period shall not be exempt from payment of the interest due pursuant to subsection (7) of this section.

(d)

No insurer shall deny a claim on the grounds of a specific policy provision, condition, or exclusion unless reference to such provision, condition, or exclusion is included in the denial. The denial shall be in writing and given to the claimant, and the claim file shall contain documentation of the basis for the denial. The commissioner may adopt a rule regarding the time period for delivery of the denial to the claimant, which shall be the same or shorter time period than the period in which the claim was delivered.

(7)

An insurer that fails to pay, deny, or settle a clean claim in accordance with paragraph (a) of subsection (6) of this section or fails to take other required action within the time periods set forth in paragraph (b) of subsection (6) of this section shall be liable for the covered benefit and, in addition, shall pay to the claimant interest at the rate of ten percent per annum for the first one hundred eighty days and at the rate of fifteen percent per annum thereafter, on the total amount ultimately allowed on the claim, accruing from the date payment was due pursuant to subsection (6) of this section. Except for shorter time periods for clean claims, all interest begins to accrue ninety calendar days after receipt of the claim by the insurer.

(8)

If an insurer delegates its claims processing functions to a third party, the delegation agreement shall provide that the claims processing entity shall comply with the requirements of this section. Any delegation by the insurer shall not be construed to limit the insurer’s responsibility to comply with this section or any other applicable provision of this article.

(9)

This section shall not apply to claims filed pursuant to the “Workers’ Compensation Act of Colorado”, articles 40 to 47 of title 8, C.R.S.

(10)

The commissioner may investigate claims against an insurer that is authorized to conduct business in this state when such claims are filed by a provider related to the improper handling or denial of benefits pursuant to this section.

(11)

The commissioner may impose, after proper notice and hearing, any other penalties set forth in this title against an insurer who has a pattern and practice of violations of this section.

(12)

When an insured entitled to benefits under medical payments coverage is injured or believes that he or she has been injured in an accident and is examined or treated by a health-care provider, such health-care provider shall notify the insurer within thirty calendar days after the insured’s initial visit. This subsection (12) shall not apply to a hospital or other health facility or entity licensed or certified pursuant to section 25-1.5-103 (1), C.R.S.

Source: Section 10-4-642 — Prompt payment of direct benefits - legislative declaration - definitions, https://leg.­colorado.­gov/sites/default/files/images/olls/crs2023-title-10.­pdf (accessed Dec. 24, 2024).

10‑4‑101
Legislative declaration 10‑4‑102
Federal “voluntary fair access to insurance required, property insurance program” - state qualification 10‑4‑103
Voluntary partial payment of liability claims without admission of liability 10‑4‑104
Competency of minor to contract for insurance - nonavoidance 10‑4‑105
Valuation of bonds and policies other than life 10‑4‑106
Assigned risks 10‑4‑106.5
Medical malpractice insurers - requirement to provide information to the department of public health and environment 10‑4‑107
Cancellation of medical malpractice policies 10‑4‑108
Notice 10‑4‑109
Nonrenewal of medical malpractice policies 10‑4‑109.5
Notice of intent prior to unilateral increase in premium or decrease in coverage previously provided in medical malpractice policies 10‑4‑109.6
Medical malpractice insurers - protections relating to reproductive health care - definition 10‑4‑109.7
Notice of intent prior to cancellation of certain policies of insurance 10‑4‑110
Notice of intent prior to nonrenewal of certain policies of insurance 10‑4‑110.3
Exclusions where claim involves sexual misconduct - void 10‑4‑110.4
Exclusion - claims involving loss in progress not known to insured 10‑4‑110.5
Notice of intent prior to unilateral increase in premium or decrease in coverage previously provided in certain policies of insurance 10‑4‑110.6
Homeowner’s insurance - definition 10‑4‑110.7
Cancellation or nonrenewal - homeowner’s insurance policies 10‑4‑110.8
Homeowner’s insurance - prohibited and required practices - estimates of replacement value - additional living expense coverage - copies of policies - personal property contents coverage - inventory of personal property - requirements concerning total loss scenarios resulting from wildlife disasters - definitions - rules 10‑4‑110.9
Fire insurance - issuance and renewal of policies within federally designated disaster areas 10‑4‑111
Summary disclosure forms required 10‑4‑112
Property damage - time of payment 10‑4‑113
Exemptions 10‑4‑114
Requirements on hazard insurance coverage for loans secured by real property 10‑4‑115
Private utilization review 10‑4‑116
Use of credit information 10‑4‑117
Loss history information report - notice to insured - definition 10‑4‑118
Severability 10‑4‑119
Monthly and electronic payment of premiums 10‑4‑120
Unfair or discriminatory trade practices - legislative declaration 10‑4‑121
Authority of insurer to protect policyholders’ property - emergency 10‑4‑301
Bond executed by surety company 10‑4‑302
Release of surety - other security 10‑4‑303
Application for release of surety - refund 10‑4‑304
Place of deposit 10‑4‑305
Bond part of expense 10‑4‑401
Purpose - applicability 10‑4‑402
Definitions 10‑4‑403
Standards for rates - competition - procedure - requirement for independent actuarial opinions regarding 1991 legislation 10‑4‑404
Rate administration 10‑4‑404.5
Rating plans - property and casualty type II insurers - rules 10‑4‑405
Filing of rating information - certain coverages 10‑4‑406
Review of filings - certain coverages 10‑4‑407
Hearings 10‑4‑408
Rating organization - study of workers’ compensation rates - premium reductions - adoption of rules 10‑4‑409
Rates furnished - cooperation among organizations 10‑4‑410
Advisory organizations 10‑4‑411
Joint underwriting 10‑4‑412
Assigned risk motor vehicle insurance 10‑4‑413
Records required to be maintained 10‑4‑414
Examinations 10‑4‑415
Prohibition against anticompetitive behavior 10‑4‑416
Prohibiting changes in rates or coverages 10‑4‑417
False or misleading information 10‑4‑418
Enforcement procedures - penalties 10‑4‑419
Claims-made policy forms 10‑4‑419.5
Workers’ compensation form certification 10‑4‑420
Risk management procedures 10‑4‑421
Notice of rate increases and decreases 10‑4‑501
Short title 10‑4‑502
Legislative declaration 10‑4‑503
Definitions 10‑4‑504
Scope 10‑4‑505
Construction 10‑4‑506
Colorado insurance guaranty association 10‑4‑507
Board of directors 10‑4‑508
Powers and duties of association 10‑4‑508.5
Aggregate liability of association 10‑4‑509
Plan of operation 10‑4‑510
Duties and powers of commissioner 10‑4‑511
Effect of paid claims 10‑4‑512
Nonduplication of recovery 10‑4‑513
Prevention of insolvencies 10‑4‑514
Examination of association 10‑4‑515
Tax exemption 10‑4‑516
Recognition of assessments in rates 10‑4‑517
Immunity 10‑4‑518
Stay of proceedings 10‑4‑519
Termination - distribution of funds 10‑4‑520
Advertising 10‑4‑601
Definitions 10‑4‑601.5
Administrative authority 10‑4‑602
Basis for cancellation 10‑4‑603
Notice 10‑4‑604
Nonrenewal 10‑4‑604.5
Issuance or renewal of insurance policies - proof of insurance provided by certificate, card, or other media 10‑4‑605
Proof of notice 10‑4‑606
Further notice 10‑4‑607
Immunity 10‑4‑608
Exemptions 10‑4‑609
Insurance protection against uninsured motorists - applicability 10‑4‑610
Property damage protection against uninsured motorists 10‑4‑611
Elimination of discounts - damage by uninsured motorist 10‑4‑613
Glass repair and replacement 10‑4‑614
Inflatable restraint systems - replacement - verification of claims - definition 10‑4‑615
Motorist insurance identification database program - reporting required - fine 10‑4‑616
Disclosure of credit reports 10‑4‑617
Insurers - biannual fee - auto theft prevention authority 10‑4‑619
Coverage compulsory 10‑4‑620
Required coverage 10‑4‑621
Required coverages are minimum 10‑4‑622
Required provision for intrastate and interstate operation 10‑4‑623
Conditions and exclusions 10‑4‑624
Self-insurers 10‑4‑625
Premium payments 10‑4‑626
Prohibited reasons for nonrenewal or refusal to write policy of automobile insurance applicable to this part 6 10‑4‑627
Discriminatory standards - premiums - surcharges - proof of financial responsibility requirements 10‑4‑628
Refusal to write - changes in - cancellation - nonrenewal of policies prohibited 10‑4‑629
Cancellation - renewal - reclassification 10‑4‑630
Exclusion of named driver 10‑4‑632
Reduction in rates for drivers aged fifty-five years or older who complete driver’s education course - legislative declaration 10‑4‑633
Certification of policy and notice forms 10‑4‑633.5
Automobile insurance policies - plain language required - rules 10‑4‑634
Assignment of payment for covered benefits 10‑4‑635
Medical payments coverage - exceptions - definitions 10‑4‑636
Disclosure requirements for automobile insurance products offered - rules 10‑4‑637
No discrimination by profession 10‑4‑638
Retroactive adjustment of health-care service claims 10‑4‑639
Claims practices for property damage 10‑4‑640
Operator’s policy of insurance 10‑4‑641
Rules - medical payments coverage 10‑4‑642
Prompt payment of direct benefits - legislative declaration - definitions 10‑4‑643
Electronic claim forms - rules 10‑4‑1001
Short title 10‑4‑1002
Definitions 10‑4‑1003
Disclosure of information 10‑4‑1004
Evidence - confidential 10‑4‑1005
Immunity 10‑4‑1006
Enforcement 10‑4‑1007
Penalty 10‑4‑1008
Municipal ordinances - concurrent jurisdiction - common law 10‑4‑1009
Continuing duties of insurers - unfair claim settlement practices 10‑4‑1201
Definitions 10‑4‑1202
Minimum standards 10‑4‑1203
Disclosure 10‑4‑1204
Penalties 10‑4‑1205
Applicability 10‑4‑1206
Effective date 10‑4‑1301
Legislative declaration 10‑4‑1302
Definitions 10‑4‑1303
Temporary joint underwriting association 10‑4‑1304
Board of directors - authority 10‑4‑1305
Plan of operation - annual certification 10‑4‑1306
Deficits - assessment - rebate of surplus 10‑4‑1307
Annual statements 10‑4‑1308
Examinations 10‑4‑1309
Legislative declaration - authority of commissioner - emergency rules - judicial review 10‑4‑1310
Privileged communications 10‑4‑1311
Tax exemption 10‑4‑1401
Legislative declaration 10‑4‑1402
Rules 10‑4‑1403
Exemption from rate filing, approval, and form certification requirements 10‑4‑1404
Multistate insurance risks - choice of law 10‑4‑1501
Definitions 10‑4‑1502
Licensure of vendors 10‑4‑1503
Requirements for sale of portable electronics insurance 10‑4‑1504
Authority of vendors of portable electronics 10‑4‑1505
Suspension or revocation of license 10‑4‑1506
Termination of portable electronics insurance 10‑4‑1507
Application for license - fees 10‑4‑1601
Definitions 10‑4‑1602
Exemptions 10‑4‑1603
Requirements for sale of consumer goods service contracts - definitions 10‑4‑1604
Obligations of reimbursement insurance companies 10‑4‑1605
Required disclosures - reimbursement insurance policy 10‑4‑1606
Required disclosures - service contracts 10‑4‑1607
Prohibited acts 10‑4‑1608
Required record keeping 10‑4‑1609
Enforcement provisions - rules 10‑4‑1701
Definitions 10‑4‑1702
Authority to issue license 10‑4‑1703
License - application - restrictions 10‑4‑1704
Disclosures to occupant 10‑4‑1705
Supervision of issuance - training 10‑4‑1706
Compensation 10‑4‑1707
Exemption from requirements 10‑4‑1708
Notification 10‑4‑1709
Enforcement 10‑4‑1801
Short title 10‑4‑1802
Legislative declaration 10‑4‑1803
Definitions 10‑4‑1804
Fair access to insurance requirements plan association - creation - participation required 10‑4‑1805
Fair access to insurance requirements plan association - board of directors - membership - duties 10‑4‑1806
FAIR plan - plan requirements - insurer requirements 10‑4‑1807
Plan of operation - mandatory components - amendments - revocation by commissioner - rules 10‑4‑1808
FAIR plans - requirements for licensed producers 10‑4‑1809
Assessment of fees 10‑4‑1810
Enforcement - suspension or revocation of certificate of authority - fines 10‑4‑1811
Appeals - judicial review 10‑4‑1812
Rules
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Current through Fall 2024

§ 10-4-642’s source at colorado​.gov