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State guide

Colorado

Pick the kind of plan you have to see who to call first. Colorado can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

  • Your employer pays claims itself

    Colorado usually cannot help with these plans. Call the Employee Benefits Security Administration.

    Call 1-866-444-3272

  • Insurance you buy, or an employer plan bought from an insurer

    Call Colorado Division of Insurance (part of the Colorado Department of Regulatory Agencies). See the at-a-glance box.

    Call 303-894-7490

  • Medicaid or children's coverage

    Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Colorado.

    Medicaid in Colorado

  • Medicare

    Colorado State Health Insurance Assistance Program (Colorado SHIP), housed in the Colorado Division of Insurance gives free counseling. Or call 1-800-MEDICARE.

    Call 888-696-7213 1-800-633-4227

The short version for Colorado

Colorado runs its own independent external review, and it is free to you: state law makes the insurance company pay for it. Unusually, you send the external review request to your insurance company, not to the state; the Colorado Division of Insurance then picks the independent reviewer at random. Free help is available from the Division of Insurance's Consumer Services Team and from the nonprofit Colorado Consumer Health Initiative, and a state Behavioral Health Ombudsman helps with mental health and substance use coverage problems.

At a glance: independent review for plans Colorado regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
Colorado Division of Insurance (part of the Colorado Department of Regulatory Agencies) · 303-894-7490 or 800-930-3745 (toll free outside the Denver metro area), Monday to Friday, 8:00 a.m. to 5:00 p.m.
Independent review
A state process (Independent external review (also called an external appeal))
Deadline to request it
4 months after you receive the insurance company's denial of your internal appeal. The Division of Insurance brochure says the window is only 60 days if you chose an optional second-level appeal in an employer plan, so file within 60 days in that case to be safe.
Cost
None. Colorado law requires the insurance company to pay the cost of the independent external review.
Decision time
45 calendar days; fast track: 72 hours (your doctor must certify that waiting would seriously endanger your life, health or ability to regain maximum function; not available for care you have already received)

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

Look at your health plan identification card. The Colorado Division of Insurance says that if the card has "CO-DOI" printed on it, your plan is regulated by the Division and Colorado's insurance laws apply. If you do not see it, you may be in a self-funded employer plan, which is overseen by the federal government (the U.S. Department of Labor's Employee Benefits Security Administration, 866-444-3272); the Division's Consumer Services Team can still help you work out which kind of plan you have.

Independent (external) review

Process
A state process. Run by Colorado Division of Insurance, which randomly assigns a certified independent external review organization to each case.
Where you file
insurer
How
Send a written request to your insurance company (not to the state) using the external review request form the company must include with its final appeal denial, sign the consent to release your medical records, and attach the denial letter and any new information. The company must pass your request to the Division of Insurance within 2 business days, and the Division assigns an independent reviewer. If the company refuses to accept your request, its refusal must explain how to appeal that refusal to the Division of Insurance.
Which denials qualify
Denials of prior approval for a covered benefit; denials because the insurer says the care is not medically necessary, appropriate, effective or efficient, or is in the wrong setting or level of care; denials because the treatment is called experimental or investigational; and denials based on a plan exclusion when a medical professional gives evidence that the exclusion should not apply. There is no minimum dollar amount.
Appeal to the plan first?
Yes, in most situations you must finish the insurance company's internal appeal first. Exceptions: in an urgent case you can ask for an expedited external review at the same time as an expedited internal appeal, and if the insurance company fails to follow the appeal rules the internal process may be treated as finished so you can go straight to external review.

Official page Request form

General rules and what to send: how external review works, how to request it.

Free help in Colorado

Medicare and Medicaid in Colorado

Medicare counseling
Colorado State Health Insurance Assistance Program (Colorado SHIP), housed in the Colorado Division of Insurance · 888-696-7213 (Spanish: 866-665-9668) . Free help with Medicare appeals.
Medicaid agency
Colorado Department of Health Care Policy and Financing, which runs Health First Colorado (Colorado's Medicaid program)
Fair hearing deadline
Generally 60 days from the date on your Notice of Action (the letter with the decision) to ask the Office of Administrative Courts for a state fair hearing. Your notice states the deadline that applies to you.
Good to know
For a benefits or services decision you may have to appeal to your health plan first; follow the directions and deadlines in your letter. To keep a service that is being stopped or reduced while you appeal, your request must be received no later than 10 days from the date of action (for a health plan appeal, contact the plan within 10 days of the date on the letter). You can ask for a faster (expedited) hearing if waiting could put your life or health at risk. Requests go to the Office of Administrative Courts (phone 303-866-2000 to file, clerk's office 303-866-5626); general Medicaid questions go to the Member Contact Center at 800-221-3943. The July 2024 Member Handbook gives a different deadline for some cases: 120 days from when you receive your health plan's appeal decision.

Medicaid appeals page How Medicaid appeals work

State laws that can help

  • External review. Gives you an independent external review of a denied internal appeal within 45 days (72 hours if urgent), paid for by the insurance company, with no minimum claim amount and a decision that binds the insurer.

    Colorado Revised Statutes section 10-16-113.5; Colorado Insurance Regulation 4-2-21

  • Step therapy. Your insurer must grant an exception to "try this drug first" rules when your prescriber documents one of the listed reasons (for example the required drug is likely to harm you, has already failed, or you are stable on your current drug), must answer within 3 business days (24 hours in urgent cases), and the request is treated as granted if it does not answer in time.

    Colorado Revised Statutes section 10-16-145 (House Bill 22-1370)

  • Prior authorization. Makes an approved prior authorization last a calendar year, limits repeat approvals for previously approved long-term maintenance drugs to once every 3 years, requires insurers to post their approval, denial and appeal numbers, and requires programs that exempt qualified providers from prior authorization.

    House Bill 24-1149 (2024)

  • Mental health parity. Requires state-regulated plans and Medicaid to cover mental health and substance use care on equal terms with medical care, and requires denial letters for that care to explain your parity rights, how to reach the Division of Insurance or the Behavioral Health Ombudsman, and your right to get the medical necessity criteria free of charge.

    Behavioral Health Care Coverage Modernization Act (House Bill 19-1269)

  • Surprise billing. Along with the federal No Surprises Act, limits you to in-network cost sharing for most emergency care, for out-of-network providers at in-network facilities, and for private ground ambulance and air ambulance services.

    House Bill 19-1174 and House Bill 22-1284

  • Denial notice. Requires insurers to give specific reasons for a denial and the next appeal steps, allows 180 days to request a first-level internal appeal, and gives people with individual plans a choice between a written appeal and an appeal review meeting.

    Colorado Insurance Regulation 4-2-17; Colorado Revised Statutes section 10-16-113

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Centers for Medicare & Medicaid Services: Affordable Care Act: Working with States to Protect Consumers (State External Appeals Review Processes list)
  2. Centers for Medicare & Medicaid Services: Colorado Health Insurance Consumer Help
  3. Colorado Division of Insurance: When Your Health Insurance Company Says No (brochure)
  4. Colorado Division of Insurance: Bulletin B-4.19, Independent External Reviews for Denials of Health Claims (includes the request form)
  5. Colorado Revised Statutes section 10-16-113.5, Independent external review of adverse determinations
  6. Colorado Insurance Regulation 4-2-21, section 6, Request for External Review (3 CCR 702-4-2-21-6)
  7. Colorado Insurance Regulation 4-2-21, section 5, Notice and Disclosure of Right to External Review
  8. Colorado Insurance Regulation 4-2-21, section 9, Expedited External Review
  9. Colorado Division of Insurance: Regulation 4-2-17, Prompt Investigation of Health Claims Involving Utilization Review and Denial of Benefits
  10. Colorado Division of Insurance: File a Complaint
  11. Colorado Division of Insurance: Health Insurance
  12. Colorado Division of Insurance: Mental / Behavioral Health and Insurance (CO-DOI card tip)
  13. Colorado Division of Insurance: LGBTQ Health Care Rights and Resources (CO-DOI card tip and self-funded plans)
  14. Colorado Division of Insurance: Federal No Surprises Act / Colorado Out-of-Network Billing
  15. Colorado Division of Insurance: Senior Health Care & Medicare (Colorado SHIP)
  16. SHIP National Technical Assistance Center: Colorado
  17. 2025 Colorado Division of Insurance Annual Complaint and Recoveries Report
  18. Health First Colorado: How to appeal a health coverage or benefits decision
  19. Health First Colorado Member Handbook (July 2024)
  20. Colorado Office of Administrative Courts: Public Benefits
  21. Colorado Consumer Health Initiative: Consumer Assistance Program
  22. Behavioral Health Ombudsman of Colorado
  23. Colorado General Assembly: HB22-1370 Coverage Requirements For Health-care Products
  24. Colorado General Assembly: HB24-1149 Prior Authorization Requirements Alternatives
  25. Colorado General Assembly: HB19-1269 Mental Health Parity Insurance Medicaid
Not confirmed (11)
  • The deadline to request independent review. Colorado Revised Statutes 10-16-113.5(7) and Regulation 4-2-21 section 6 say four months after the internal appeal denial, with no shorter period; the Division of Insurance brochure says 60 days after a voluntary second-level appeal. Both are recorded; the brochure is undated and may be out of date.
  • The official independent review page. the Division of Insurance has no web page explaining external review that I could find; the link is its brochure (PDF), which is undated and prints an older office address (Suite 850; the website footer says Suite 1300).
  • The independent review request form. the link is the bulletin that contains the blank request form (Appendix A); the usable form must come from your insurance company with its own contact details filled in.
  • Not confirmed. externalReview.howToFile and mustExhaustInternalFirst — procedural details (2 business days to forward, deemed exhaustion) were read from the Cornell Legal Information Institute copy of Regulation 4-2-21, whose amendment history ends in 2023; I could not load the current regulation text on the Division of Insurance site.
  • Not confirmed. externalReview.statisticsNote / statisticsSourceUrl — no official overturn rate found; the Division's 2025 complaint report does not give one, older per-insurer reports found only for 2011 and 2014, and a 44% figure online is attributed to news coverage, not an official page.
  • A searchable list of past decisions. no searchable database of past decisions found on the Division of Insurance site.
  • The state regulators. the Division's File a Complaint page gives 303-894-7490 for the Consumer Services Team, but the footer of the same site and the federal Centers for Medicare & Medicaid Services page give 303-894-7499 as the main number; the toll-free number 800-930-3745 is the same everywhere.
  • The Medicaid fair hearing deadline. the Health First Colorado appeals web page says 60 days from the Notice of Action, including after a health plan appeal; the July 2024 Member Handbook says 120 days from receiving the health plan's appeal decision for members in managed care plans. Not reconciled.
  • Free consumer help programs. no dedicated web page was loaded for the Health First Colorado Managed Care Ombudsman; the link is the state appeals page where its phone number is printed.
  • Free consumer help programs. Colorado Legal Services phone and role are taken from the Health First Colorado appeals page (Medicaid appeals); its help with private insurance denials was not confirmed.
  • State laws that help. bill summaries were read on leg.colorado.gov through a text fetch tool; the site returned an error (HTTP 406) to a direct automated link check, so confirm the three leg.colorado.gov links open in a browser. Statute section numbers for House Bill 24-1149 and the surprise billing laws were not confirmed, so bill numbers are cited instead. No Colorado law specific to artificial intelligence in coverage decisions was researched.

Sources last checked . Found a mistake? Report it.