How to appeal a health insurance denial in Colorado
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. Colorado lets you ask an independent reviewer to decide, through Colorado Division of Insurance (Department of Regulatory Agencies). The deadline to ask: within four (4) months after the date of receipt of a notice of a carrier's adverse determination following the completion or exhaustion of the internal appeal process.
Does this apply to you? State external review covers plans regulated by Colorado: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in Colorado
Within four (4) months after the date of receipt of a notice of a carrier's adverse determination following the completion or exhaustion of the internal appeal process
The independent external review entity must decide as expeditiously as possible and no more than 72 hours after receiving an expedited request (written confirmation within 48 hours if the decision is given orally). An expedited external review can be requested at the same time as an expedited internal appeal; ask for expedited handling in your written request and include your physician's certification.
Free (the insurer pays the cost of the review)
State-regulated plans (insurance bought in Colorado or through an employer that buys insurance). Self-funded employer plans use the federal process.
You send the written request (the Division's form in Bulletin B-4.19, with a signed records-release consent) to your insurance company, not the Division; the insurer forwards it and the Division randomly assigns an independent review entity. The Division's consumer brochure says 4 months after a first-level appeal or 60 days after a voluntary second-level appeal, while the statute and Regulation 4-2-21 say four months, so file within 60 days if you used a voluntary second-level appeal. Toll-free 800-930-3745 works outside the Denver metro area; the consumer services line is 303-894-7490.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in Colorado?
Within four (4) months after the date of receipt of a notice of a carrier's adverse determination following the completion or exhaustion of the internal appeal process
Can I get a fast external review in Colorado?
The independent external review entity must decide as expeditiously as possible and no more than 72 hours after receiving an expedited request (written confirmation within 48 hours if the decision is given orally). An expedited external review can be requested at the same time as an expedited internal appeal; ask for expedited handling in your written request and include your physician's certification.
Does external review cost anything in Colorado?
Free (the insurer pays the cost of the review)
Do Colorado’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- Colorado Division of Insurance: When Your Health Insurance Company Says "No" (consumer brochure)
You have 4 months (after a first level appeal) or 60 days (after a voluntary second level appeal, if available) to send your insurance company a request for an external review.
- Colorado Insurance Regulation 4-2-21, Section 6 (3 CCR 702-4-2-21-6)
Within four (4) months after the date of receipt of a notice of a carrier's adverse determination following the completion or exhaustion of the internal appeal process
- C.R.S. 10-16-113.5 (independent external review)
An individual requesting an independent external review shall make the request within four months after receiving notification of the denial of the individual’s internal appeal of an adverse determination.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.