Arbitration Process

Flowchart of the Out-of-Network Arbitration Process

The out-of-network provider or out-of-network faciltiy may initiate arbitration by filing an Arbitration Request Form with the Commissioner of Insurance (at dora_doi_arbitration@state.co.us ) and with the insurance carrier within ninety (90) calendar days after the receipt of payment or receipt of payment instructions for that claim. The out-of-network provider or the out-of-network facility may arrange an informal settlement teleconference before an arbitrator is appointed by the Commissioner, but an informal settlement teleconference is not required.

  • If there is no request for an informal settlement teleconference, the Commissioner shall appoint an arbitrator within thirty (30) calendar days of receiving a request for arbitration.

  • If the Commissioner receives notice that an informal teleconference was not successful, the Commissioner shall appoint an arbitrator within fifteen (15) calendar days of receiving that notice.

Once an arbitrator is appointed by the Commissioner, the parties to the arbitration have thirty (30) calendar days to submit their final offers and reasoning for those offers to the arbitrator.

The arbitrator shall make a decision on the request for arbitration within forty-five (45) calendar days of appointment and will notify the parties and the Division of Insurance of the decision in writing, utilizing the Arbitration Decision and Reporting form, which can also found in Colorado Insurance Regulation 4-2-67. The party whose final offer was not chosen is responsible to pay the expenses and fees of the arbitrator.

If the informal teleconference settlement or the arbitrator’s decision requires the carrier to make an additional payment, the claim shall be readjudicated within thirty (30) calendar days, and the carrier shall notify the covered person of any change to their deductible, coinsurance, and/or copayment calculations.

If the informal settlement or arbitrator’s decision does not require the carrier to make an additional payment, the carrier shall notify the covered person of the outcome of the arbitration and advise the covered person that the non-participating provider is prohibited from billing the covered person directly except for the covered person’s required deductible, coinsurance, and/or copayment , and the provider is required to reimburse the covered person within sixty (60) calendar days after the date the provider is notified of an overpayment.

If you have any additional questions, please contact the Division at dora_doi_arbitration@state.co.us 


 

Contact Information
Division of Insurance, Colorado Department of Regulatory Agencies
1560 Broadway, Suite 850
Denver, CO 80202