Colorado § 25-37-103 - Health-care contracts - required provisions - permissible provision.

§ 25-37-103. Health-care contracts - required provisions - permissible provision.

(1) (a) A person or entity shall provide, with each health-care contract, a summary disclosure form disclosing, in plain language, the following:

(I) The terms governing compensation and payment;

(II) Any category of coverage for which the health-care provider is to provide service;

(III) The duration of the contract and how the contract may be terminated;

(IV) The identity of the person or entity responsible for the processing of the health-care provider's claims for compensation or payment;

(V) Any internal mechanism required by the person or entity to resolve disputes that arise under the terms or conditions of the contract; and

(VI) The subject and order of addenda, if any, to the contract.

(b) The summary disclosure form required by paragraph (a) of this subsection (1) shall be for informational purposes only and shall not be a term or condition of the contract; however, such disclosure shall reasonably summarize the applicable contract provisions.

(c) If the contract provides for termination for cause by either party, the contract shall state the reasons that may be used for termination for cause, which terms shall not be unreasonable, and the contract shall state the time by which notice of termination for cause shall be provided and to whom the notice shall be given.

(d) The person or entity shall identify any utilization review or management, quality improvement, or similar program the person or entity uses to review, monitor, evaluate, or assess the services provided pursuant to a contract. The policies, procedures, or guidelines of such program applicable to a provider shall be disclosed upon request of the health-care provider within fourteen days after the date of the request.

(e) (I) The summary disclosure form required by subsection (1)(a) of this section must include a disclosure that a person or entity shall not terminate a health-care contract with a health-care provider solely for the provision of, or assistance in the provision of, a legally protected health-care activity, as defined in section 12-30-121 (1)(d).

(II) A person or entity that is a religious organization is not subject to the requirements of this subsection (1)(e) if the provision of, or assistance in the provision of, a legally protected health-care activity, as defined in section 12-30-121 (1)(d), conflicts with the religious organization's bona fide religious beliefs and practices.

(2) (a) The disclosure of payment and compensation terms pursuant to subsection (1) of this section shall include information sufficient for the health-care provider to determine the compensation or payment for the health-care services and shall include the following:

(I) The manner of payment, such as fee-for-service, capitation, or risk sharing;

(II) (A) The methodology used to calculate any fee schedule, such as relative value unit system and conversion factor, percentage of medicare payment system, or percentage of billed charges. As applicable, the methodology disclosure shall include the name of any relative value system; its version, edition, or publication date; any applicable conversion or geographic factor; and any date by which compensation or fee schedules may be changed by such methodology if allowed for in the contract.

(B) The fee schedule for codes reasonably expected to be billed by the health- care provider for services provided pursuant to the contract, and, upon request, the fee schedule for other codes used by or which may be used by the health-care provider. Such fee schedule shall include, as may be applicable, service or procedure codes such as current procedural terminology (CPT) codes or health care common procedure coding system (HCPCS) codes and the associated payment or compensation for each service code.

(C) The fee schedule required in sub-subparagraph (B) of this subparagraph (II) may be provided electronically.

(D) A fee schedule for the codes described by sub-subparagraph (B) of this subparagraph (II) shall be provided when a material change related to payment or compensation occurs. Additionally, a health-care provider may request that a written fee schedule be provided up to twice per year, and the person or entity must provide such fee schedule promptly.

(III) The person or entity shall state the effect of edits, if any, on payment or compensation. A person or entity may satisfy this requirement by providing a clearly understandable, readily available mechanism, such as through a website, that allows a health-care provider to determine the effect of edits on payment or compensation before service is provided or a claim is submitted.

(b) Notwithstanding any provision of this subsection (2) to the contrary, disclosure of a fee schedule or the methodology used to calculate a fee schedule is not required:

(I) From a person or entity if the fee schedule is for a plan for dental services, its providers include licensed dentists, the fee schedule is based upon fees filed with the person or entity by dental providers, and the fee schedule is revised from time to time based upon such filings. Specific numerical parameters are not required to be disclosed.

(II) If the fee schedule is for pharmacy services or drugs such as a fee schedule based on use of national drug codes.

(3) When a proposed contract is presented by a person or entity for consideration by a health-care provider, the person or entity shall provide in writing or make reasonably available the information required in subsections (1) and (2) of this section. If the information is not disclosed in writing, it shall be disclosed in a manner that allows the health-care provider to timely evaluate the payment or compensation for services under the proposed contract. The disclosure obligations in this article shall not prevent a person or entity from requiring a reasonable confidentiality agreement regarding the terms of a proposed contract.

(4) Nothing in this article shall be construed to require the renegotiation of a contract in existence before the applicable compliance date in this article, and any disclosure required by this article for such contracts may be by notice to the health-care provider.

(5) A contract subject to this article may include an agreement for binding arbitration.

Source: L. 2010: Entire article amended with relocations, (HB 10-1332), ch. 300, p. 1416, § 1, effective May 26. L. 2023: (1)(e) added, (SB 23-188), ch. 68, p. 251, § 25, effective April 14.

Editor's note: This section is similar to former § 25-37-101 (3), (4), (6), (9), and (19) as they existed prior to 2010.

Cross references: For the legislative declaration in SB 23-188, see section 1 of chapter 68, Session Laws of Colorado 2023.