Insurance Carriers Are Required to Reimburse Providers for Emergency Services Related to COVID-19, Including Out-Of-Network Providers

What you need to know about DOI Emergency Regulation 20-E-07

When is this regulation effective?
April 18, 2020

Which plans does this apply to?
The regulation applies to all carriers offering individual, small group, large group plans, managed care plans, and student health insurance coverage that are CO-DOI regulated and subject to the ACA.

What criteria must be met for diagnosis and treatment to be covered as an emergency?
A positive or presumed positive test, and/or a provider documenting the patient as having COVID-19 constitutes covering all services rendered to the patient as emergent. If a patient is determined not to have COVID-19, emergency treatment shall continue to be covered to the extent required by §10-16-704(5.5) C.R.S.

How will providers be reimbursed?
Treatment of COVID-19 is subject to provider reimbursement requirements, in-network benefits, direct payment rules, and consumer protections against balance billing according to §10-16-704(5.5) C.R.S.

What about out-of-network reimbursement?
For the purposes of treating COVID-19 during this emergency, all treatment provided at out-of-network facilities shall be considered emergency services ancillary to the emergency dept. of a hospital and necessary to treat the emergency medical condition in order to stabilize the patient.

Carriers shall reimburse out-of-network providers for emergency services rendered for the treatment of COVID-19 pursuant to §10-16-704(5.5) C.R.S.

Are prior authorization requirements suspended?
Yes, for emergency services provided to patients with emergency medical conditions.

Does this regulation still apply to claims submitted after the public health emergency ends for services that occurred during the emergency?

I am an out-of-network provider who wishes to take claims to arbitration. Can I bundle COVID-19-related claims?
Yes. For the duration of the COVID-19 emergency and the run-out of COVID-19-related claims, out-of-network providers are allowed to bundle COVID-19-related claims for the purposes of arbitration.

Categories: Resources, COVID