Network Access Plan for HMO Colorado Members
At HMO Colorado, a subsidiary company of Anthem Blue Cross and Blue Shield, we work hard to help ensure our members have access to a network of providers that will meet their health care needs. This network includes physicians and other health care providers who deliver quality care and who offer convenient office hours and locations. Providers in our network are available to members for a full range of covered health care services to help them stay healthy. Providers play an important role in helping us achieve our mission—to improve the health of the people we serve.
Our network access plan describes the process HMO Colorado uses to develop and maintain adequate provider access, which is one of our primary responsibilities to our members. Providers play an important role in helping us achieve our mission: to improve the lives of the people we serve and the health of our communities.
HMO Colorado members must select a primary care physician (PCP) from our network. PCPs include internists, family and general practice physicians, and pediatricians. Members contact their PCP when they need medical care. The PCP will get to know the member’s health care needs and recommend specialists when needed. For the best possible coordination of overall care and for a recommendation on which physician specialist to see, we encourage HMO members to talk to their PCP.
PCPs in the HMO Colorado network (or their physician’s on-call) are available to members 24 hours a day, seven days a week.
A PCP in the HMO Colorado network may be part of a medical management group or may be contracted independently with HMO Colorado. If a PCP is part of a medical management group, the PCP will typically refer members to specialists in the same medical management group. Or, the PCP may refer members to any provider in HMO Colorado’s broad network for specialty care.
If a PCP is part of a medical management group, the PCP and medical specialists in that group work as a team with the member to personalize health care decisions. This team approach allows the doctors to share information and encourages communication about the member’s medical care.
For a comprehensive directory that lists providers and facilities in the HMO Colorado network here
, or call Customer Service at the phone number listed on the back of your health plan ID card.
A member’s PCP is available to provide advice to the member about health care concerns. However, in a life- or limb-threatening situation that requires immediate medical care to prevent death or serious impairment of health, MEMBERS SHOULD CALL 911 OR IMMEDIATELY GO TO THE NEAREST EMERGENCY FACILITY
. Members should then contact their PCP as soon as possible.
The PCP will then be aware of the member’s condition and can coordinate follow-up care.
Selecting and Changing PCPs
When selecting a PCP from the HMO Colorado network, members have several options. They may choose a physician they know, one located close to their home or office, or one that is in the same medical management group as their specialist provider. We encourage members to get to know their PCP to establish a common understanding of health care needs and goals. To change PCPs, members may fill out this form
, go to MyAnthem.com or call Customer Service at the phone number listed on the back of your health plan ID card.
Notice of Provider Changes/Terminations
When a PCP’s contract with HMO Colorado terminates, we send a letter to members who have chosen that PCP and ask them to select a new PCP. After the member selects a new PCP, we issue the member a new health plan ID card with updated information.
When a specialist’s contract with HMO Colorado terminates, we work with the specialist to identify HMO Colorado members in the specialist’s care. We then help those members transition to another provider in a timely manner.
When the provider initiates the termination, the provider agrees to continue ongoing treatment of HMO Colorado members until the treatment is completed or until continued care can be arranged.
Note: In the unlikely event that HMO Colorado ceases to operate, members are protected from responsibility for unpaid provider claims. HMO Colorado will cooperate fully with state regulators to ease the transition to a new health insurance carrier, including notifying members that it has ceased operations and is transferring members to other providers in a timely manner.
Open Access: Referrals Not Required to See In-network Physician Specialists
The PCP is the member’s first point of contact when care is needed. When a member needs specialist care, the PCP can recommend an appropriate specialty provider.
Members are not required to obtain a referral from their PCP to see a physician specialist in the HMO Colorado network. However, preauthorization is required for certain services and procedures. In-network providers are responsible for obtaining preauthorization when it is required.
HMO Colorado members are generally required to see in-network providers for non-emergency care. Under certain non-emergency circumstances, members may see an out-of-network provider, although preauthorization is required in those cases. Members are responsible for confirming that preauthorization is obtained when seeing an out-of-network provider and the member’s out-of-pocket costs may be higher for those services.
If preauthorization is not obtained when required for out-of-network care, the member will be financially responsible for those services.
Preauthorization is required when HMO Colorado point-of-service members see an out-of network provider for certain services or procedures. Member’s out-of-pocket costs may be higher. To obtain additional information, members may go to anthem.com, or call Customer Service from 7:30 a.m.-5:30 p.m., Monday through Friday, at the phone number listed on the back of your health plan ID card.
HMO Colorado’s comprehensive specialty network includes physician specialists (surgeons, allergists, dermatologists, cardiologists, etc.); other specialists (physical therapists, home health agencies, etc.); facilities (acute care hospitals, ambulatory care centers, hospices, etc.); and providers of other specialty care, including rehabilitation services.
Specialist recommendations within a medical management group
When a member’s PCP is part of a medical management group and the member asks the PCP for a specialist recommendation, the PCP will typically refer the member to a specialist within the same medical management group. If preauthorization is required but not obtained for care received from an out-of-network provider, the member will be financially responsible for those services.
Specialist recommendations through independent PCPs
Members whose PCP is not affiliated with a medical management group will make recommendations to any specialty provider within the HMO Colorado network. Whether members seek specialty care on their own or receive a recommendation from their PCP, it is important to stay within the HMO Colorado provider network
to maximize reimbursement through the member’s benefit plan.
Members can access hospital services at the 70 HMO Colorado network hospitals. Whether members seek hospital care on their own (emergency) or receive a recommendation from their PCP or specialists, it is important to stay within the HMO Colorado provider network to maximize reimbursement through the member’s benefit plan. To obtain additional information, members may go to anthem.com, or call Customer Service, Monday through Friday, at the phone number listed on the back of your health plan ID card.
Behavioral health services
Before receiving behavioral health and chemical dependency services, HMO Colorado members must call our behavioral health services toll-free number at 800-424-4014 for authorization. Behavioral health services representatives then help members find an appropriate provider in the HMO Colorado network. A referral from the member’s PCP is not required. A comprehensive directory that lists providers and facilities in the HMO Colorado network is available at anthem.com. or by calling our customer service department at the phone number listed on the back of your health plan ID card.
HMOSelect is a smaller subset of our statewide HMO network. The product is available to all small group employers in the seven county Denver Metro area as well as Elbert, El Paso and Teller counties. The product is also available to governmental entities and not for profit 501 (c) 3 large groups in the Denver Metro area and all large groups in Elbert, El Paso and Teller counties. The network is based around Centura Health’s hospitals, i.e. Avista, Littleton, Parker, Porter, Saint Anthony North, and Saint Anthony Central in Denver, and Penrose in Colorado Springs.
In addition, the following hospitals are participating in the network, Children’s, Denver Health, National Jewish and University. The physician network is made up of physicians with privileges at one of the above facilities who have executed a contract with us for HMOSelect. There are well over 2,000 physicians in the network not including the behavioral health network and chiropractic network.
Network Development Strategy
When HMO Colorado develops a network, the following factors, among others, are considered:
| Which and how many providers work in the area|
| Which providers meet HMO Colorado’s quality standards|
| Which providers want to contract with HMO Colorado|
| How many members does HMO Colorado anticipate enrolling|
| Which providers are important to specific employer groups or other groups of members|
| What are the PCP referral patterns in the area, i.e., who do PCPs normally send their patients to for specialty care|
Network Adequacy Standards and Monitoring
HMO Colorado’s quality management program establishes standards, or minimum requirements, to help ensure that our members have adequate access to physicians, hospitals and other health care providers.
HMO Colorado considers many factors in order to identify, evaluate and remedy problems concerning access to care and the continuity and quality of care, including:
| The distance members must travel to see a provider receive hospital services.|
| The percentage of PCPs accepting new members, i.e., those who have “open” practices.|
| The number of PCPs compared to the number of members|
| The number of frequently seen specialists and sub-specialists compared to the number of members.|
| The waiting time between a member’s call for an appointment and the appointment time and date.|
| The office hours and on-call availability of providers.|
| The volume of technological and specialty services available to serve the needs of members who require covered technologically advanced or specialty care.|
HMO Colorado monitors and helps ensure compliance with these standards by reviewing reports that assess the size and distribution of the network, evaluating member satisfaction surveys, and developing surveys that focus on monitoring compliance with the standards.
HMO Colorado developed the adequacy standards described in this network access plan after reviewing national health care resources for guidance on best industry practices.
We review these standards, or minimum requirements, and monitor compliance annually. We then design action plans to address opportunities for improvement that are identified during the process. This may include working with providers in the HMO Colorado network or contracting with out-of-network providers.
|Definitions of Levels of Medical Care
Regular or routine medical care
Comprehensive care that emphasizes prevention, early detection and early treatment of conditions through routine physical exams, immunizations and health education
Urgent medical care
Care provided for individuals who require immediate medical attention but whose condition is not life-threatening (non-emergency), e.g., high fever, cuts requiring stitches
|Level of Care or Service
|HMO Colorado Standard|
|Waiting Time for Care from the Member’s Primary Care Physician|
PCP regular/routine medical care
85% of members always and usually get care when needed
PCP urgent medical care
75% of members always and usually get care as soon as they need
After-hours medical care (PCP or on-call physician)
Available 24 hours per day, 7 days per week
|Primary Care Physicians Accepting New Patients|
Percent with “open” practices
At least 65%
|Access to HMO Colorado Customer Service|
Average speed of answer
30 seconds or less
Less than 5%
|Waiting Time for Behavioral Health Care |
Routine medical care
Outpatient Therapist (non-MD)
Prescribing Providers (MD/DO)
Urgent medical care
Outpatient Therapists (non-MD)
Prescribing Providers (MD/DO)
Emergency care, non-life threatening
Outpatient Therapists (non-MD)
Prescribing Providers (MD/DO)
Within 6 hours
Outpatient Therapists (non-MD)
Prescribing Providers (MD/DO)
85% of providers have after-hours
|Access to Behavioral Health Care|
Average speed of answer
Less than 30 seconds
Less than 3%
|Number of Primary Care Providers Compared to the Number of Members|
PCPs – internists, family and general practice physicians, and pediatricians
20 providers per 10,000 members
|Number of Most Frequently Seen Specialists and Subspecialists Compared to the Number of Members|
2.9 providers per 10,000 members
0.6 providers per 10,000 members
0.7 providers per 10,000 members
0.5 providers per 10,000 members
2.0 providers per 10,000 members
Non-MD Behavioral Health
8.0 providers per 10,000 members
|Distance Members Have to Travel to Reach a Provider|
PCPs – urban counties*
2 providers in 20 miles
PCPs – rural counties **
2 providers in 60 miles
All specialists – urban counties*
2 providers in 45 miles
All specialists – rural counties**
1 provider in 100 miles
Behavioral Health – specialists (MD and non-MD practitioner) – urban counties*
1 provider within 10 miles
Behavioral Health – specialists (MD and non-MD practitioner) – rural counties**
1 provider within 40 miles
Hospitals – urban counties*
1 provider in 30 miles
Hospitals – rural counties**
1 provider in 60 miles
Behavioral Health – hospitals – urban counties*
1 hospital within 25 miles
Behavioral Health – hospitals – rural counties**
1 hospital within 45 miles
Pharmacies – urban counties
1 provider in 3 miles
Pharmacies – suburban counties
1 provider in 5 miles
Pharmacies – rural counties
1 provider in 15 miles
Assisting Members with Special Needs
Transition of care
When benefits end while a member still needs care, HMO Colorado assists with the transition by offering to educate the member about alternatives for continuing care and, as appropriate, how to obtain continuing care. HMO Colorado’s clinical care coordinator completes this process.
Continuity of care
When members join or leave HMO Colorado, they may have to change physicians. HMO Colorado provides coverage for continuing care that was in progress before a new member’s effective date with HMO Colorado, if the services were in-network under the prior carrier’s plan. Benefits are also allowed if HMO Colorado experiences significant disruption due to provider contract terminations.
Continuing care may be allowed for:
| A pregnant member who is in the second or third trimester of pregnancy, through the postpartum timeframe.|
| Elective surgeries approved by the prior carrier’s preauthorization process, if the surgery was previously scheduled and if HMO Colorado determines that it is a covered benefit.|
| Ongoing treatment for an acute inpatient episode or chronic condition.|
| Home health care, home IV therapy and durable medical equipment approved by the prior carrier or medical management group|
| Rehabilitation programs|
| Life-threatening conditions|
| Terminal illnesses|
In these situations, HMO Colorado, the primary care physician, the specialist and the member work together. They try to complete treatment with the existing providers or transfer care to HMO Colorado providers.
HMO Colorado also cooperates with other health plans when a member leaves HMO Colorado.
Members with Physical and Mental Disabilities (Needs)
The provider directory indicates provider locations that are accessible to members with disabilities. Arrangements will be made for members who require other assistance, such as special communication tools.
HMO Colorado Customer Service representatives are available to assist with members’ special needs.
Non-English Speaking Members
Providers who speak languages in addition to English are identified in HMO Colorado’s provider directory.
When non-English-speaking members call our Customer Service department, we communicate with them through a translation connection with AT&T. The Customer Service representative connects the member with a translator from AT&T via teleconference to complete the service call. This allows us to accommodate 140 different languages.
Some member materials are available in Spanish and are furnished on request.
We continually strive to identify and address the unique needs of our members and address those needs through our provider networks and through company initiatives.
HMO Colorado has a quality management program designed to evaluate the quality, appropriateness and outcomes of care and services. We also monitor how care and services are delivered to HMO Colorado members. During this process, we place emphasis on identifying opportunities for improvement and problem-solving.
The program is directed by the West Region Strategic Planning Committee. The Quality Management Committee (QMC), which includes external network physicians along with Anthem’s quality department staff, provides clinical expertise and recommendations for the implementation of the QM program.
We use standards developed by national organizations for developing, maintaining and reporting quality management program activities.
Programs to Improve Member Health Care Needs and Health Outcomes
The quality management program uses a structured process to evaluate and improve the program, including:
| Reviewing important aspects of care and service.|
| Identifying opportunities for improvement.|
| Designing improvement initiatives.|
| Implementing the initiatives.|
| Evaluating the effect of the initiatives.|
One important aspect of this process includes analyzing the specific health care needs of HMO Colorado members. By reviewing claims data, surveys and member demographic data (chronic diseases, cultural backgrounds, etc.), HMO Colorado identifies certain populations, such as members who have diabetes or asthma, and targets programs to improve the health of those members.
We also review specific populations to help ensure that our network includes an adequate number of providers, including specialists, to serve those populations.
HMO Colorado places a priority on preventing illness and delivering the appropriate care in the appropriate setting. For example, women who do not receive their annual cervical cancer screening are identified by claims records and
are reminded of the importance of the screening via phone or mail.
HMO Colorado conducts several member surveys. These surveys help us understand how members feel about various aspects of their health care benefits plan, such as the waiting time for appointments, their satisfaction with the care received and the number of providers in our network.
The surveys are used to identify opportunities for improvement. We then build action plans around these opportunities.
Communicating with Members
This network access plan is one way we inform members about HMO Colorado’s provider network. We also communicate information about our provider network and the health plan’s services and features through the following: certificates, member handbook, newsletters, and the website.
HMO Colorado’s provider directory lists PCPs (internists, family and general practice physicians, and pediatricians); specialty physicians (e.g., surgeons, allergists, dermatologists, cardiologists and psychiatrists); facilities (acute care hospitals, ambulatory care centers and skilled nursing facilities); and other medical specialty providers (e.g., physical therapists, home health agencies, substance abuse facilities, rehabilitation services and IV therapy laboratories).
The provider directory is available clicking here
or by calling our Customer Service department at the phone number listed on the back of your health plan ID card. An online provider directory is available in Spanish and is located at Anthem en Espanol accessible from the home page of anthem.com
. In addition to a list of providers, the directory includes information about how to use the network.
Members enrolling in a HMO Colorado health care benefits plan have access to their certificate via Anthem’s website. This certificate describes the benefits available to the member and how to use those benefits. It also describes HMO Colorado’s grievance procedures, the availability of specialty medical services and HMO Colorado’s process for preauthorizing medical care. New and renewing members receive information about how to access their certificate with their health plan ID card(s).
As a supplement to the certificate, the member handbook summarizes the essential information about the member’s health care benefits plan. The member hand book is available on anthem.com.
Healthy Solutions newsletter
This periodic newsletter is mailed to members at their home address at no additional cost. In addition to information designed to help members maintain and improve their health, the newsletter also may include articles on benefits and provider networks.
HMO Colorado Customer Service representatives are available to assist members. To help them better serve our customers, these representatives receive specialized training in areas such as service skills, problem-solving, our benefit plans and our provider networks. Our representatives are available Monday through Friday, at the phone number listed on the back of your health plan ID card.
Members Concerns (Clinical Grievance, Complaints and Appeals)
Members who have a concern about services received from HMO Colorado or about the care or services received from a provider in the HMO Colorado network may call HMO Colorado customer service at the phone number listed on the back of your health plan ID card.
A clinical grievance occurs if you have an issue or concern about the quality or services you receive from a provider or facility in HMO Colorado’s network. The quality management department strives to resolve clinical grievances fairly and quickly. We will work to clear up any confusion, settle your concerns and make sure appropriate action is taken.
To Initiate A Clinical Grievance:
A member may send a written clinical grievance to the following address:
Anthem Blue Cross (Anthem)
PO Box 4310
Woodland Hills, CA 91367
Anthem’s quality management department will acknowledge receipt of and investigate the member’s clinical grievance. The quality management department treats each clinical grievance investigation in a strictly confidential manner.
A problem concerning any aspect of HMO Colorado’s services or claims processing is a complaint. A Customer Service representative will work with the member to clear up any confusion and resolve difficulties.
To Initiate A Complaint:
If a member has a complaint about any aspect of HMO Colorado’s service or claims processing, the member should contact Anthem’s Customer Service Department. A Customer Service representative will work to clear up any confusion and resolve the member’s concerns. A member may submit a written complaint to the following address:
Customer Service Department
P.O. Box 5747
Denver, CO 80217-5747
If a member is not satisfied with the information provided by the HMO Colorado Customer Service representative during resolution of a complaint, the member may file an appeal, as explained below.
Members may go through the complaint process before filing an appeal or may choose to file an appeal without first going through the complaint process. There are two types of appeals: a utilization review (UR) appeal and a non-utilization review (non-UR) appeal. Non-UR appeals include appeals about certificate exclusions, benefit maximums and other non-UR claims denials.
To File an Appeal:
Where HMO Colorado’s actions have resulted in an adverse benefit determination (e.g. a claim for services or request for preauthorization which has been denied in whole or in part), the member may appeal the adverse benefit determination. An appeal may be filed with or without first submitting a complaint. The member’s appeal must be in writing (except for expedited utilization review appeals). While HMO Colorado encourages members to file appeals within 60 calendar days of the adverse benefit determination, HMO Colorado must receive the member’s written appeal within 180 calendar days of the member’s receipt of the adverse benefit determination. Members may send written appeals to the following address:
700 Broadway CAT 0430
Denver, CO 80273-0001
In the written appeal, the member must state plainly the reason(s) the member believes the claim or requested service or supply should not have been denied. The member has the right, and is encouraged to submit written comments, documents, records or other information relevant to the appeal. HMO Colorado will assign an employee to assist the member in the appeal process.
Members may designate a representative (e.g., the member’s physician, counsel, advocate or anyone else of the member's choosing) to file or pursue any level of appeal review with HMO Colorado on the member’s behalf. When a member designates a representative to file an appeal on the member’s behalf, the member must provide HMO Colorado with this designation in writing.
The member may access two internal levels of appeal. Additionally, in the case of a benefit denial based on utilization review, an independent external review appeal is available to the member.
“Utilization review” means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review. For the purposes of this Guide, utilization review shall also include reviews for the purpose of determining coverage based on whether or not a procedure or treatment is considered experimental or investigational in a given circumstance, and reviews of a member’s medical circumstances when necessary to determine if an exclusion applies in a given situation. A denial on the basis that the treatment, drug or device is excluded by the member’s policy will be considered a denial based on utilization review, provided the member presents evidence from a medical professional licensed under the Colorado Medical or Dental Practice law, that there is a reasonable medical basis that the contractual exclusion does not apply.
Level 1 Appeal: During the first level of appeal, HMO Colorado appoints an internal person or persons not involved in the initial determination to review the denial of the claim or requested service or supply. A person who was previously involved with the denial may answer questions. A Level 1 appeal involving utilization review will be evaluated by a physician who will consult with an appropriate clinical peer(s), unless the reviewing physician is a clinical peer.
“Clinical peer” means a physician or other health care professional who holds a non-restricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review.
Where the benefit in question was denied due to a contractual exclusion, in order to secure a Level 1 appeal involving utilization review, the member must be able to provide evidence from a medical professional that there is a reasonable medical basis that the exclusion does not apply. In such an event, the determination shall be made on the basis of whether the contractual exclusion applies to the denied benefit.
The member does not have the right to attend the Level 1 appeal, but the member is entitled to submit written comments, documents, records and other material relating to the request for benefits for the reviewer(s) to consider. The member may also identify providers to whom HMO Colorado shall send a copy of the Level 1 appeal decision. The member also has the right to receive, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to the member’s request for benefits. In conducting the Level 1 appeal, the reviewer(s) will consider all of the comments, documents, records and other information regarding the request for services submitted by the member, regardless of whether that information was submitted or considered in connection with the initial adverse benefit determination.
HMO Colorado will notify the member of the outcome of a Level 1 appeal involving utilization review within 30 calendar days of receipt of the appeal request. Level 1 appeals which do not involve utilization review will be resolved within 30 calendar days (60 calendar days for post-service claims) of receipt of the appeal request. The appeal decision timeframes may be extended if the member requests or voluntarily agrees to the extension.
Voluntary Level 2 Appeal: If the adverse benefit determination has not been resolved to the member’s satisfaction under the Level 1 appeal process, the member has the option (but not the obligation) to utilize a Level 2 internal appeal. HMO Colorado will provide the covered person, upon request, sufficient information relating to the voluntary Level 2 review to enable the member to make an informed judgment about whether to submit the adverse determination to the Level 2 appeal review. The member’s decision to pursue, or not pursue, a Level 2 appeal will have no effect on the member’s right to any other benefit under the insurance policy or certificate.
If the member chooses to pursue a Level 2 appeal, the Level 2 appeal must be requested within 60 calendar days after the member receives HMO Colorado’s decision of the Level 1 appeal. In connection with a Level 2 appeal, the member has the right to (i) request the opportunity to appear in person or by teleconference before the Level 2 appeal panel; (ii) prepare in advance for the appeal review and receive from HMO Colorado, upon request, copies of all documents, records and other information HMO Colorado intends to present at the Level 2 appeal review, at least 5 days prior to the review;; (iii) present the member’s case to the appeal panel; (iv) submit written comments, documents, records and other material relating to the request for benefits for the appeal panel to consider when conducting the review both before and, if applicable, at the appeal meeting (a copy of the materials the member plans to present should be provided to HMO Colorado at least 5 days prior to the date of the review meeting); (v) if applicable, ask questions of any representative of HMO Colorado or the review panel; (vi) be assisted or represented at the appeal meeting by an individual of the member’s choice and bring counsel, advocates and healthcare professionals to the appeal meeting; and (vii) identify any providers to whom HMO Colorado will send a copy of the Level 2 appeal decision.
The panel of reviewers will include a minimum of three people and may be composed of HMO Colorado associates who have appropriate professional expertise. A majority of the panel will be comprised of persons who were not previously involved in the dispute; however, a person who was previously involved with the dispute may be a member of the panel or appear before the panel to present information or answer questions. In the case of utilization review appeals, the person(s) reviewing the appeal will be health care professional(s) who have appropriate expertise in relation to the case presented by the member. Such reviewing health care professional(s) will not have been involved in the member’s appeal review process or the member’s care previously, and will not have a direct financial interest in the case or the outcome of the review.
HMO Colorado will schedule and hold the Level 2 appeal meeting within 60 days of receiving the member’s request for a Level 2 appeal. The member will be notified in writing, at least 20 days prior to the Level 2 appeal review date. If HMO Colorado wishes to have an attorney to represent its interests at the meeting, it will notify the member that an attorney will be present, and advise the member that the member may wish to obtain legal representation of his/her own. If the member intends to have an attorney represent the member’s interests at the meeting, the member should notify HMO Colorado at least 7 days prior to the meeting, where practicable. In addition, in connection with the Level 2 appeal of a denial involving utilization review, HMO Colorado shall make an audio or video recording of the review unless neither the member nor HMO Colorado wants the recording made and this recording will be made available to the member. If there is an external review of the Level 2 appeal decision, the recording will, at the request of either party, be included in the material provided by HMO Colorado to the reviewing entity.
In conducting the review, the appeal panel will consider all of the comments, documents, records and other information regarding the request for services submitted by the member, regardless of whether that information was submitted or considered in connection with the Level 1 appeal decision. Where the Level 2 appeal concerns a denial due to a contractual exclusion and involves utilization review, the determination shall be made on the basis of whether the contractual exclusion applies to the denied benefit.
Unless the member requests otherwise in connection with a Level 2 appeal involving utilization review, HMO Colorado will not allow an audio or videotape recording of the appeal meeting to be made. After private deliberation, the appeal panel will issue a written decision, which will be provided to the member within 7 days of completing the appeal meeting.
Expedited Appeals: A member or a member’s representative (including the member’s practitioner) has the right to request an expedited review if handling the appeal as a standard appeal: (1) could seriously jeopardize the member’s life, health or ability to regain maximum function; (2) would, in the opinion of a physician with knowledge of the member’s medical condition, subject the member to severe pain that cannot be adequately managed without the service or treatment in question; or (3) would, for persons with a disability, create an imminent and substantial limitation on their existing ability to live independently. In addition, expedited review is granted to all requests concerning admissions, continued stay or other health care services for a member who has received emergency services but who has not been discharged from a facility. HMO Colorado will not provide an expedited review for retrospective denials. The request for Expedited appeal may be oral or made in writing.
Expedited appeals will be evaluated by an appropriate clinical peer or peers not involved in the initial denial. The member does not have the right to attend the Expedited appeal, but the member is entitled to submit written comments, documents, records and other material relating to the request for benefits for the reviewer(s) to consider. The member may also identify providers to whom HMO Colorado shall send a copy of the expedited appeal decision. The member also has the right to receive, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to the member’s request for benefits. In conducting the Expedited appeal, the reviewer(s) will consider all of the comments, documents, records and other information regarding the request for services submitted by the member, regardless of whether that information was submitted or considered in connection with the initial adverse benefit determination. The decision will be expeditiously made, and the member or representative will be notified of the decision within 72 hours of the request. HMO Colorado will notify the member and the member’s provider via phone or e-mail and within 3 days, follow up in writing regarding the determination of the Expedited appeal. If the Expedited appeal does not resolve the adverse benefit determination to the member’s satisfaction, the member may pursue either a Voluntary Level 2 Appeal as noted above or an Independent External Review Appeal.
Independent External Review Appeals: When the adverse benefit determination involves utilization review, the member may request an Independent External Review Appeal. The member must have exhausted the Level 1 Appeal, but may make such a request either after, or instead of, exercising the right to file a Voluntary Level 2 Appeal. Independent External Review Appeals are conducted by independent external review entities, which are selected by the Colorado Division of Insurance. To request an Independent External Review Appeal, the member or member’s representative must complete and submit a written request on a Request for Independent External Review of Carrier’s Final Adverse Determination Form, which is available through HMO Colorado’s Customer Service Department. The request must be made to HMO Colorado within 60 calendar days after the date of receipt of notice of HMO Colorado’s final appeal denial. The Division of Insurance will assign an independent external review entity to conduct the review. The independent reviewer’s decision will be made within 30 business days after HMO Colorado receives a request for such a review. This timeframe may be extended up to 10 business days for the consideration of additional material, if requested by the independent external review entity.
Expedited Independent External Review Appeals: A member or a member’s representative may request an expedited independent external review appeal if the member has a medical condition for which the timeframe for a standard independent external review appeal would seriously jeopardize the member’s life or health; jeopardize the member’s ability to regain maximum function; or, for persons with a disability, create an imminent and substantial limitation on the member’s existing ability to live independently. The member’s request must include a physician’s certification that the member’s medical condition meets the criteria for an expedited independent external review appeal. The request must be made on the form referenced in the paragraph above. Determinations will be made by the independent external review entity within seven business days after HMO Colorado receives a request for an expedited independent external review appeal. This timeframe may be extended for an additional five business days for the consideration of additional information, if requested by the independent external review entity. An expedited independent external review appeal may not be provided for retrospective denials.
Before legal action is taken on a claim decision, members must request a Level 1 appeal. Subsequent levels of appeals are voluntary and are not required before pursuing legal action.
Arbitration procedures – If any party involved is not satisfied with HMO Colorado’s decision as explained under the appeal procedures heading, the party may pursue the remedies available under the Employee Retirement Income Security Act of 1974 (ERISA) and/or binding arbitration, whichever is applicable to the member’s health care benefits plan. Any party alleging a claim against HMO Colorado, including a claim for denial of benefits or coverage, must follow the process described under the appeal procedures heading before instituting a legal proceeding, suit or arbitration against HMO Colorado.
Legal action – Before a member takes legal action on a claim decision:
| The member must first follow the Level 1 appeal process outlined under the appeal procedures heading. Subsequent levels of appeal are voluntary and are not required before pursuing legal action.|
| The member must meet all requirements of the member’s certificate.|
| No action in law or equity will be brought to recover before the expiration of 60 calendar days after written proof of loss has been filed according to the requirements of the member’s certificate.|
| No such action will be brought at all unless it is brought within three years of the time within which written proof of loss has been filed as required by the member’s certificate.|
The HMO Colorado network access plan is designed to assist our members in understanding their benefits and how to access the providers and hospitals available to them through HMO Colorado’s health care benefits plans. If you have any questions about your plan or the information in this document, please call Customer Service at the phone number listed on the back of your health plan ID card.