Colorado § 25.5-1-204.7 - All-payer health claims database - creation of tool for review of data included in the database - definitions.

§ 25.5-1-204.7. All-payer health claims database - creation of tool for review of data included in the database - definitions.

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

(a) "Administrator" means the administrator of the all-payer health claims database.

(b) "All-payer health claims database" or "database" means the all-payer health claims database created pursuant to section 25.5-1-204.

(c) "Code" means CPT code, HCPCS code, or other packaged services or industry standard procedure code that may include time units, base unit values, or modifiers.

(d) "CPT code" means the current procedural terminology code, or its successor code, as developed and copyrighted by the American Medical Association or its successor entity.

(e) "Healthcare common procedure coding system code" or "HCPCS code" means the code established by the federal centers for medicare and medicaid services' alpha-numeric editorial panel for identifying health-care services in a consistent and standardized manner.

(f) "Private health-care payer" means a carrier, as defined in section 10-16-102 (8), that reports claims received from an out-of-network provider pursuant to section 12-30-113 (4).

(g) "Tool" means the tool developed by the administrator pursuant to this section to enable users to review certain health claims reimbursement data in the database.

(2) (a) To facilitate the accurate determination of the reimbursement rates pursuant to sections 10-16-704 (3)(d) and (5.5)(b), 12-30-113 (4), and 25-3-122 (3) and to provide transparency in the process, subject to available appropriations, the administrator shall create and maintain a tool for implementation by January 1, 2023, that enables users to review certain health claims reimbursement data included in the all-payer health claims database. The tool must include 2018 health claims reimbursement data as the first year of data.

(b) To the extent practicable, the tool must, at a minimum:

(I) Include twenty-fifth, fiftieth, sixtieth, and seventy-fifth percentile of in-network reimbursement rates based on claims and the number of claims submitted for each code by payer type, for all codes with sufficient volume reported to the database, for three years of data; and

(II) Be viewable and searchable by:

(A) Year;

(B) County;

(C) Geographic rating area and statewide;

(D) Payer type, including medicaid, medicare, and private health-care payers;

(E) Setting, including inpatient and outpatient services; and

(F) Specialty.

(c) The administrator shall ensure that the viewing or reporting of health claims data through the tool complies with all state and federal data privacy laws and antitrust laws.

(3) Subject to available appropriations, the administrator shall update the tool annually and may update the tool more frequently as determined by the administrator.

Source: L. 2022: Entire section added, (SB 22-068), ch. 266, p. 1935, § 1, effective May 27.