C.R.S. § 25-37-101 Applicability of article
25-37-101. Applicability of article. A person or entity that contracts with a health-care provider shall comply with this article and shall include the provisions required by this article in the contract.
Contracts with Health-care Providers
C.R.S. tit. 25, art. 37
in effectC.R.S. § 25-37-102 Definitions
25-37-102. Definitions. 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(4) Repealed.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.
at 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.
C.R.S. § 25-37-103 Health-care contracts - required provisions - permissible provision
25-37-103. Health-care contracts - required provisions - permissible provision. (1) (a) A person or entity shall provide, with each health-care contract, a summary disclosure form disclosing, in plain language, the following:
(I) The terms governing compensation and payment;
(II) Any category of coverage for which the health-care provider is to provide service;
(III) The duration of the contract and how the contract may be terminated;
(IV) The identity of the person or entity responsible for the processing of the health-care provider's claims for compensation or payment;
(V) Any internal mechanism required by the person or entity to resolve disputes that arise under the terms or conditions of the contract; and
(VI) The subject and order of addenda, if any, to the contract.
(b) The summary disclosure form required by paragraph (a) of this subsection (1) shall be for informational purposes only and shall not be a term or condition of the contract; however, such disclosure shall reasonably summarize the applicable contract provisions.
(c) If the contract provides for termination for cause by either party, the contract shall state the reasons that may be used for termination for cause, which terms shall not be unreasonable, and the contract shall state the time by which notice of termination for cause shall be provided and to whom the notice shall be given.
(d) The person or entity shall identify any utilization review or management, quality improvement, or similar program the person or entity uses to review, monitor, evaluate, or assess the services provided pursuant to a contract. The policies, procedures, or guidelines of such program applicable to a provider shall be disclosed upon request of the health-care provider within fourteen days after the date of the request.
(e) (I) The summary disclosure form required by subsection (1)(a) of this section must include a disclosure that a person or entity shall not terminate a health-care contract with a health-care provider solely for the provision of, or assistance in the provision of, a legally protected health-care activity, as defined in section 12-30-121 (1)(d).
(II) A person or entity that is a religious organization is not subject to the requirements of this subsection (1)(e) if the provision of, or assistance in the provision of, a legally protected health-care activity, as defined in section 12-30-121 (1)(d), conflicts with the religious organization's bona fide religious beliefs and practices.
(2) (a) The disclosure of payment and compensation terms pursuant to subsection (1) of this section shall include information sufficient for the health-care provider to determine the compensation or payment for the health-care services and shall include the following:
(I) The manner of payment, such as fee-for-service, capitation, or risk sharing;
(II) (A) The methodology used to calculate any fee schedule, such as relative value unit system and conversion factor, percentage of medicare payment system, or percentage of billed charges. As applicable, the methodology disclosure shall include the name of any relative value system; its version, edition, or publication date; any applicable conversion or geographic factor; and any date by which compensation or fee schedules may be changed by such methodology if allowed for in the contract.
(B) The fee schedule for codes reasonably expected to be billed by the health- care provider for services provided pursuant to the contract, and, upon request, the fee schedule for other codes used by or which may be used by the health-care provider. Such fee schedule shall include, as may be applicable, service or procedure codes such as current procedural terminology (CPT) codes or health care common procedure coding system (HCPCS) codes and the associated payment or compensation for each service code.
(C) The fee schedule required in sub-subparagraph (B) of this subparagraph (II) may be provided electronically.
by the health-care provider. Such fee schedule shall include, as may be applicable, service or procedure codes such as current procedural terminology (CPT) codes or health care common procedure coding system (HCPCS) codes and the associated payment or compensation for each service code.
(C) The fee schedule required in sub-subparagraph (B) of this subparagraph (II) may be provided electronically.
(D) A fee schedule for the codes described by sub-subparagraph (B) of this subparagraph (II) shall be provided when a material change related to payment or compensation occurs. Additionally, a health-care provider may request that a written fee schedule be provided up to twice per year, and the person or entity must provide such fee schedule promptly.
(III) The person or entity shall state the effect of edits, if any, on payment or compensation. A person or entity may satisfy this requirement by providing a clearly understandable, readily available mechanism, such as through a website, that allows a health-care provider to determine the effect of edits on payment or compensation before service is provided or a claim is submitted.
(b) Notwithstanding any provision of this subsection (2) to the contrary, disclosure of a fee schedule or the methodology used to calculate a fee schedule is not required:
(I) From a person or entity if the fee schedule is for a plan for dental services, its providers include licensed dentists, the fee schedule is based upon fees filed with the person or entity by dental providers, and the fee schedule is revised from time to time based upon such filings. Specific numerical parameters are not required to be disclosed.
(II) If the fee schedule is for pharmacy services or drugs such as a fee schedule based on use of national drug codes.
(3) When a proposed contract is presented by a person or entity for consideration by a health-care provider, the person or entity shall provide in writing or make reasonably available the information required in subsections (1) and (2) of this section. If the information is not disclosed in writing, it shall be disclosed in a manner that allows the health-care provider to timely evaluate the payment or compensation for services under the proposed contract. The disclosure obligations in this article shall not prevent a person or entity from requiring a reasonable confidentiality agreement regarding the terms of a proposed contract.
(4) Nothing in this article shall be construed to require the renegotiation of a contract in existence before the applicable compliance date in this article, and any disclosure required by this article for such contracts may be by notice to the health-care provider.
(5) A contract subject to this article may include an agreement for binding arbitration.
C.R.S. § 25-37-103.5 Pharmacy benefit managers - contracts with pharmacies - maximum allowable cost pricing
25-37-103.5. Pharmacy benefit managers - contracts with pharmacies - maximum allowable cost pricing. (Repealed)
C.R.S. § 25-37-104 Material change in health-care contract - written advance notice
25-37-104. Material change in health-care contract - written advance notice. (1) A material change to a contract shall occur only if the person or entity provides in writing to the health-care provider the proposed change and gives ninety days' notice before the effective date of the change. The writing shall be conspicuously entitled "notice of material change to contract".
(2) If the health-care provider objects in writing to the material change within fifteen days and there is no resolution of the objection, either party may terminate the contract upon written notice of termination provided to the other party not later than sixty days before the effective date of the material change.
(3) If the health-care provider does not object to the material change pursuant to subsection (2) of this section, the change shall be effective as specified in the notice of material change to the contract.
(4) If a material change is the addition of a new category of coverage and the health-care provider objects, the addition shall not be effective as to the health-care provider, and the objection shall not be a basis upon which the person or entity may terminate the contract.
C.R.S. § 25-37-105 Contract modification by operation of law
25-37-105. Contract modification by operation of law. Notwithstanding section 25-37-103 (3), a contract may be modified by operation of law as required by any applicable state or federal law or regulation, and the person or entity may disclose this change by any reasonable means.
C.R.S. § 25-37-106 Clean claims - development of standardized payment rules and code edits - task force to develop - legislative recommendations - short title - applicability
25-37-106. Clean claims - development of standardized payment rules and code edits - task force to develop - legislative recommendations - short title - applicability. (Repealed)
C.R.S. § 25-37-107 Claim adjudication information - balance owing
25-37-107. Claim adjudication information - balance owing. Upon completion of processing of a claim, the person or entity shall provide information to the health-care provider stating how the claim was adjudicated and the responsibility for any outstanding balance of any party other than the person or entity.
C.R.S. § 25-37-108 Assignment of rights - requirements
25-37-108. Assignment of rights - requirements. (1) A person or entity shall not assign, allow access to, sell, rent, or give the person's or entity's rights to the health-care provider's services pursuant to the person's or entity's contract unless the person or entity complies with the requirements of this section.
(2) A person or entity may assign, allow access to, sell, rent, or give his, her, or its rights to the health-care provider's services pursuant to the person's or entity's contract if one of the following situations exists:
(a) The third party accessing the health-care provider's services under the contract is an employer or other entity providing coverage for health-care services to its employees or members and such employer or entity has, with the person or entity contracting with the health-care provider, a contract for the administration or processing of claims for payment or service provided pursuant to the contract with the health-care provider;
(b) The third party accessing the health-care provider's services under the contract is an affiliate of, subsidiary of, or is under common ownership or control with the person or entity; or, is providing or receiving administrative services from the person or entity or an affiliate of, or subsidiary of, or is under common ownership or control with the person or entity; or
(c) The health-care contract specifically provides that it applies to network rental arrangements and states that it is for the purpose of assigning, allowing access to, selling, renting, or giving the person's or entity's rights to the health-care provider's services.
(3) In addition to satisfying the requirements of subsection (2) of this section, a person or entity may assign, allow access to, sell, rent, or give his, her, or its rights under the contract to the services of the health-care provider only if:
(a) The individuals receiving services under the health-care provider's contract are provided with appropriate identification stating where claims should be sent and where inquiries should be directed; and
(b) The third party accessing the health-care provider's services through the health-care provider's contract is obligated to comply with all applicable terms and conditions of the contract; except that a self-funded plan receiving administrative services from the person or entity or its affiliates shall be solely responsible for payment to the provider.
C.R.S. § 25-37-109 Waiver of rights prohibited
25-37-109. Waiver of rights prohibited. Except as permitted by this article, a person or entity shall not require, as a condition of contracting, that a health-care provider waive or forego any right or benefit to which the health-care provider may be entitled under state or federal law, rule, or regulation that provides legal protections to a person solely based on the person's status as a health-care provider providing services in this state.
C.R.S. § 25-37-110 Provider declining service to new patients - notice - definition
25-37-110. Provider declining service to new patients - notice - definition. (1) Upon sixty days' notice, a health-care provider may decline to provide service pursuant to a contract to new patients covered by the person or entity. The notice shall state the reason or reasons for this action.
(2) As used in this section, "new patients" means those patients who have not received services from the health-care provider in the immediately preceding three years. A patient shall not become a "new patient" solely by changing coverage from one person or entity to another person or entity.
C.R.S. § 25-37-111 Termination of contract - effect on payment terms - right to terminate - termination of pharmacy contracts
25-37-111. Termination of contract - effect on payment terms - right to terminate - termination of pharmacy contracts. (1) A term for compensation or payment shall not survive the termination of a contract, except for a continuation of coverage required by law or with the agreement of the health-care provider.
(2) In addition to the right to terminate a contract in accordance with section 25-37-104 (2) based on a material change to the contract, a contract with a duration of less than two years shall provide to each party a right to terminate the contract without cause, which termination shall occur with at least ninety days' written notice. For contracts with a duration of two or more years, termination without cause may be as specified in the contract.
(3) A contract between a pharmacist or a pharmacy and a pharmacy benefit manager, such as a pharmacy benefit management firm as defined in section 10-16-102, C.R.S., shall be terminated if the federal drug enforcement agency or other federal law enforcement agency ceases the operations of the pharmacist or pharmacy due to alleged or actual criminal activity.
C.R.S. § 25-37-112 Disclosure to third parties - confidentiality
25-37-112. Disclosure to third parties - confidentiality. A contract shall not preclude its use or disclosure to a third party for the purpose of enforcing the provisions of this article or enforcing other state or federal law. The third party shall be bound by the confidentiality requirements set forth in the contract or otherwise.
C.R.S. § 25-37-113 Article inapplicable - when
25-37-113. Article inapplicable - when. (1) [Editor's note: This version of the introductory portion to subsection (1) is effective until July 1, 2025.] This article shall not apply to:
(1) [Editor's note: This version of the introductory portion to subsection (1) is effective July 1, 2025.] This article 37 does not apply to:
(a) An exclusive contract with a single medical group in a specific geographic area to provide or arrange for health-care services; however, this article shall apply to contracts for health-care services between the medical group and other medical groups;
(b) A contract or agreement for the employment of a health-care provider or a contract or agreement between health-care providers;
(c) A contract or arrangement entered into by a hospital or health-care facility that is licensed or certified pursuant to section 25-3-101;
(d) [Editor's note: This version of subsection (1)(d) is effective until July 1, 2025.] A contract between a health-care provider and the state or federal government or their agencies for health-care services provided through a program for workers' compensation, medicaid, medicare, the children's basic health plan provided for in article 8 of title 25.5, C.R.S., or the Colorado indigent care program created in part 1 of article 3 of title 25.5, C.R.S.;
(d) [Editor's note: This version of subsection (1)(d) is effective July 1, 2025.] A contract between a health-care provider and the state or federal government or their agencies for health-care services provided through a program for workers' compensation, medicaid, medicare, or the children's basic health plan provided for in article 8 of title 25.5;
(e) Contracts for pharmacy benefit management, such as with a pharmacy benefit management firm as defined in section 10-16-102, C.R.S.; except that this exclusion shall not apply to a contract for health-care services between a person or entity and a pharmacy, pharmacist, or professional corporation or corporate entity consisting of pharmacies or pharmacists as permitted by the laws of this state; or
(f) A contract or arrangement entered into by a hospital or health-care facility that is licensed or certified pursuant to section 25-3-101, or any outpatient service provider that has entered into a joint venture with the hospital or is owned by the hospital or health-care facility.
C.R.S. § 25-37-114 Enforcement
25-37-114. Enforcement. (1) With respect to the enforcement of this article, including arbitration, there shall be available:
(a) Private rights of action at law and in equity;
(b) Equitable relief, including injunctive relief;
(c) Reasonable attorney fees when the health-care provider is the prevailing party in an action to enforce this article, except to the extent that the violation of this article consisted of a mere failure to make payment pursuant to a contract;
(d) The option to introduce as persuasive authority prior arbitration awards regarding a violation of this article.
(2) Arbitration awards related to the enforcement of this article may be disclosed to those who have a bona fide interest in the arbitration.
C.R.S. § 25-37-115 Providers obligated to comply with law
25-37-115. Providers obligated to comply with law. No provision of this article shall be used to justify any act or omission by a health-care provider that is prohibited by any applicable professional code of ethics or state or federal law prohibiting discrimination against any person.
C.R.S. § 25-37-116 Copyrights protected
25-37-116. Copyrights protected. Nothing in this article, including the designation of standards, code sets, rules, edits, or related specifications, divests copyright holders of their copyrights in any work referenced in this article.
Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://leg.colorado.gov/sites/default/files/images/olls/crs2024-title-25.docxFetched: 10/6/2026