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Member Appeals and Dispute Resolution Rule Update

Member Appeals and Dispute Resolution Rule Update

The Department invites you to provide feedback to help inform and refine changes to the member appeals rule. There will also be time for policy questions and clarification.  

Wednesday, March 27, 2024 3:00-4:00 p.m. Agenda

Register in advance or at the start of the webinar https://us02web.zoom.us/webinar/register/WN_rDwzKoyYSeKqrV4Bl_GNiQ. You will receive a confirmation email with information to join the webinar.

Dial-In: +1 484-841-8349 (Toll free) 
Passcode: 903429737

The Department is revising its member appeals rule to reflect long-standing current practices. MSB 23-11-29-A. Member Appeals. County informal dispute resolution conferences are available to members and applicants who are found to be ineligible for the Colorado medical assistance program - i.e., eligibility appeals. Counties have no involvement in utilization management and medical necessity reviews for benefit appeals, and informal dispute resolutions conferences are not, and have never been, available to members for such appeals. The purpose of the rule change is to clarify that county or service delivery agency informal dispute resolution conferences are only for eligibility appeals.

Separately, this proposed rule change removes language from 8.057 regarding possible recoupments from members who receive services during their appeals and later lose the appeals. This change is to comply with a CMS waiver under Section 1902(e)(14)(A); and to harmonize with Department practices of not recouping in these circumstances.

The authority for this rule is contained in 25.5-1-301 through 25.5-1-303, C.R.S. (2011).

Reference Information

Stakeholders may provide written comment or request a virtual meeting by emailing HCPF_HPO_PDI_StakeholderEngagement@state.co.us.