Colorado SB 22-097 requires health insurers to respond to standard prior authorization requests within 7 business days and urgent requests within 3 business days. PA denial notices must cite specific clinical criteria and reviewer credentials. Electronic PA portals are mandated under federal CMS-0057-F.
Prior Authorization Response Timelines
Colorado establishes two decision timelines for PA requests:
| Request Type | Timeline |
|---|---|
| Standard PA | 7 business days |
| Urgent PA | 3 business days |
These timelines apply to all state-regulated health plans. Emergency services are not subject to PA requirements; retrospective review is permitted after emergency care.
Electronic Prior Authorization Portals
Federal regulations (CMS-0057-F) require electronic PA portals effective 2026. Colorado health plans must support electronic PA submission and provide the same response timelines as paper submissions. Electronic submission improves accuracy and can accelerate decision turnaround.
Denial Requirements and Clinical Justification
PA denials must include: (1) specific clinical criteria cited by the plan, (2) clinical rationale with reviewer credentials, and (3) clear appeal instructions. The denial notice must enable the provider to understand the clinical basis and prepare an informed appeal.
Appeals and External Review
Patients and providers have 180 days from PA denial to file an internal appeal. External review through the Colorado Division of Insurance is available if the internal appeal is denied. The Division appoints independent medical reviewers to conduct objective clinical review of PA determinations.
Regulatory Oversight and Enforcement
The Colorado Division of Insurance monitors PA compliance and conducts market conduct examinations. PA practices are reviewed for timeliness, clinical justification, and adherence to approval/denial criteria. Systemic violations trigger regulatory enforcement action.
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Frequently Asked Questions
What is Colorado's timeline for standard PA decisions?
Colorado SB 22-097 requires health plans to respond to standard prior authorization requests within 7 business days. Urgent/expedited PA requests must be resolved within 3 business days.
How do I file an external review of a denied Colorado prior auth?
After internal appeal denial, request external independent review from the Colorado Division of Insurance. File within the appeal timeline specified in the insurer's denial notice, typically 180 days from denial.
Related Resources
- Colorado Timely Filing Requirements
- Colorado Surprise Billing Law
- All State Billing Laws
- Prior Authorization Rules Overview