Colorado § 25-3-122 - Out-of-network facilities - emergency medical services - billing - payment - unfair or deceptive trade practice.

§ 25-3-122. Out-of-network facilities - emergency medical services - billing - payment - unfair or deceptive trade practice.

(1) If a covered person receives emergency services at an out-of-network facility, the out-of-network facility 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 a covered person receives emergency services at an out-of-network facility, and the facility 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 facility shall reimburse the covered person within sixty calendar days after the date that the overpayment was reported to the facility.

(b) An out-of-network facility 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 facility received the notice of the overpayment. The covered person is not required to request the accrued interest from the out-of-network health-care facility in order to receive interest with the reimbursement amount.

(3) (a) An out-of-network facility, other than any out-of-network facility operated by the Denver health and hospital authority pursuant to article 29 of title 25, must send a claim for emergency services to the carrier within one hundred eighty days after the receipt of insurance information in order to receive reimbursement as specified in this subsection (3)(a). The reimbursement rate is the greater of:

(I) One hundred five percent of the carrier's median in-network rate of reimbursement for that service provided in a similar facility or setting in the same geographic area; or

(II) The median in-network rate of reimbursement for the same service provided in a similar facility or setting in the same geographic area for the prior year based on claims data from the all-payer health claims database created in section 25.5-1-204.

(b) An out-of-network facility operated by the Denver health and hospital authority created in section 25-29-103 must send a claim for emergency services to the carrier within one hundred eighty days after the delivery of services in order to receive reimbursement as specified in this subsection (3)(b). The reimbursement rate is the greater of:

(I) The carrier's median in-network rate of reimbursement for the same service provided in a similar facility or setting in the same geographic area;

(II) Two hundred fifty percent of the medicare reimbursement rate for the same service provided in a similar facility or setting in the same geographic area; or

(III) The median in-network rate of reimbursement for the same service provided in a similar facility or setting in the same geographic area for the prior year based on claims data from the Colorado all-payer health claims database described in section 25.5-1-204.

(c) If the out-of-network facility submits a claim for emergency services after the one-hundred-eighty-day period specified in this subsection (3), the carrier shall reimburse the facility one hundred twenty-five percent of the medicare reimbursement rate for the same services in a similar setting or facility in the same geographic area.

(d) The out-of-network facility 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.

(4) An out-of-network facility may initiate arbitration pursuant to section 10-16-704 (15) if the facility believes the payment made pursuant to subsection (3) of this section is not sufficient.

(5) This section does not apply when a covered person voluntarily uses an out-of-network provider.

(6) A violation of this section is an unfair or deceptive trade practice pursuant to section 6-1-105 (1)(rrr).

Source: L. 2019: Entire section added, (HB 19-1174), ch. 171, p. 1994, § 6, effective January 1, 2020. L. 2023: (6) added, (SB 23-093), ch. 152, p. 649, § 12, effective May 4. L. 2026: (6) amended, (HB 26-1426), ch. 334, p. 2027, § 100, effective August 12.

Cross references: For definitions applicable to this section, see § 25-3-121 (4).