State RegulationsCO specificDifficulty 2/5
A Colorado insured receives an adverse determination from her carrier's utilization review program. Under C.R.S. § 10-16-113.5 and related Division of Insurance rules, she is generally entitled to:
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
C.R.S. § 10-16-113.5 and the related Division of Insurance utilization review rules entitle an insured who receives an adverse utilization review determination to pursue the established appeal and review procedures rather than accept the denial as final. Colorado Insurance Regulation 4-2-21 is among the Division's utilization review regulations addressing review of adverse determinations.
Why the other options are wrong
- B) An adverse determination does not trigger automatic payment; the insured uses the established review procedures.
- C) Utilization review determinations are not final and unreviewable; appeal procedures exist.
- D) A premium refund is not the remedy for an adverse utilization review determination.
Memory hook
Adverse UR decision? Appeal rights apply.