As used in this article 37, unless the context
otherwise requires:
(1) Category of coverage means one of the following types of coverage
offered by a person or entity:
(a) Health maintenance organization plans;
(b) Any other commercial plan or contract that is not a health maintenance
organization plan;
(c) Medicare;
(d) Medicaid; or
(e) Workers' compensation.
(2) CMS means the federal centers for medicare and medicaid services in
the United States department of health and human services.
(3) CPT code set means the current procedural terminology code, or its
successor code, as developed and copyrighted by the American medical
association, or its successor entity, and adopted by the CMS as a HIPAA code set.
(4) Repealed.
(5) HCPCS means the Healthcare Common Procedure Coding System
developed by the CMS for identifying health-care services in a consistent and
standardized manner.
(6) Health-care contract or contract means a contract entered into or
renewed between a person or entity and a health-care provider for the delivery of
health-care services to others.
(7) Health-care provider means a person licensed or certified in this state
to practice medicine, pharmacy, chiropractic, nursing, physical therapy, podiatry,
dentistry, optometry, occupational therapy; to practice as a certified midwife; or to
practice other healing arts. Health-care provider also means an ambulatory
surgical center, a licensed pharmacy or provider of pharmacy services, and a
professional corporation or other corporate entity consisting of licensed health-care providers as permitted by the laws of this state.
(8) HIPAA code set means any set of codes used to encode elements, such
as tables of terms, medical concepts, medical diagnostic codes, or medical
procedure codes, that have been adopted by the secretary of the United States
department of health and human services pursuant to the federal Health Insurance
Portability and Accountability Act of 1996, as amended. HIPAA code set includes
the codes and the descriptors of the codes.
(9) (a) Material change means a change to a contract that decreases the
health-care provider's payment or compensation, changes the administrative
procedures in a way that may reasonably be expected to significantly increase the
provider's administrative expense, replaces the maximum allowable cost list used
with a new and different maximum allowable cost list by a person or entity for
reimbursement of generic prescription drug claims, or adds a new category of
coverage.
(b) Material change does not include:
(I) A decrease in payment or compensation resulting solely from a change in
a published fee schedule upon which the payment or compensation is based and
the date of applicability is clearly identified in the contract;
(II) A decrease in payment or compensation resulting from a change in the
fee schedule specified in a contract for pharmacy services such as a change in a fee
schedule based on average wholesale price or maximum allowable cost;
(III) A decrease in payment or compensation that was anticipated under the
terms of the contract, if the amount and date of applicability of the decrease is
clearly identified in the contract;
(IV) An administrative change that may significantly increase the provider's
administrative expense, the specific applicability of which is clearly identified in the
contract;
(V) Changes to an existing prior authorization, precertification, notification,
or referral program that do not substantially increase the provider's administrative
expense; or
(VI) Changes to an edit program or to specific edits; however, the person or
entity shall provide notice of the changes to the health-care provider in accordance
with paragraph (c) of this subsection (9), and the notice shall include information
sufficient for the health-care provider to determine the effect of the change.
(c) If a change to the contract is administrative only and is not a material
change, the change shall be effective upon at least fifteen days' notice to the
health-care provider. All other notices shall be provided pursuant to the contract.
(10) National correct coding initiative or NCCI means the system
developed by the CMS to promote consistency in national correct coding
methodologies and to control improper coding leading to inappropriate payment in
medicare part B claims for professional services.
(11) National initiative means a collaborative effort led by or occurring
under the direction of the secretary of the United States department of health and
human services, which includes a diverse group of stakeholders, to create a level of
understanding of the impact of coding edits on the industry and a uniform,
standardized set of claim edits that meets the needs of the stakeholders in the
industry.
(12) Person or entity means a person or entity that has a primary business
purpose of contracting with health-care providers for the delivery of health-care
services.
(13) Pharmacy benefit manager means an entity doing business in this
state that contracts to administer or manage prescription drug benefits on behalf
of any carrier that provides prescription drug benefits to residents of this state.
Pharmacy benefit manager does not include the department of health care policy
and financing created in section 25.5-1-104, C.R.S.