How appeals work in Colorado
When a Colorado-regulated carrier denies, delays, or changes coverage, you usually receive an adverse determination notice. That notice should explain how to request internal review—often called first level review or an appeal.
Internal review means the carrier (or its review organization) reconsiders the decision. If you still lose, many Coloradans can request independent external review through the Division of Insurance.
Universal how-to: Appeals roadmap and Building a strong appeal packet.
One level or two?
Colorado law treats group and individual plans differently (C.R.S. § 10-16-113):
- Individual health plans: generally one level of required internal review, then external review if allowed
- Group employer plans: must offer two levels of internal review—but the second level is voluntary (you choose whether to use it before external review)
The denial letter tells you which levels apply and how to file. You may bring an advocate, counsel, or treating provider to a review meeting in many cases.
The usual steps
- Adverse determination — the first denial (often after prior authorization or utilization review).
- First level review — file a grievance/appeal with the carrier within the deadline on your notice (often up to 180 calendar days from the adverse determination under DOI rules).
- Voluntary second level (some group plans only) — optional; you have about 60 calendar days after the first-level denial to request it.
- Independent external review — see Colorado external review.
DOI consumer guide: When Your Health Insurance Company Says "No" (PDF).
How long the carrier has to answer
Under Colorado regulations (3 CCR 702-4), after you file first level review:
- Pre-service (prospective) denials: written decision within 30 calendar daysof the carrier's receipt of your appeal (3 CCR 702-4-2-17-11)
- Post-service (retrospective) denials: written decision within 60 calendar days
- Urgent cases: expedited timelines—often 72 hours when health is at serious risk
Carriers must give you written notice of the decision, the basis for it, and your right to external review if the internal appeal is denied (C.R.S. § 10-16-113.5).
If the carrier is late
If the carrier does not meet required internal review deadlines, you may be treated as having exhausted internal review and can move toward external review. Keep proof of when you filed and calendar the dates on your notice.
For voluntary second-level review, the carrier must generally schedule a review meeting within 60 calendar days of your request (3 CCR 702-4-2-17-11).
What comes next?
After internal appeal is denied, you generally have four months to request independent external review (C.R.S. § 10-16-113.5(7)). If you used a voluntary second level, DOI materials note a 60-day window from that denial in some cases—follow the letter you receive.
Colorado external review · Self-funded ERISA plans
Health First Colorado: plan appeal first, then Office of Administrative Courts fair hearing—see Colorado: Start Here.
Key takeaway
Read the adverse determination notice, file first level review before the filing deadline, and track the 30- or 60-day answer window. Group members can skip voluntary level two and go straight to external review after level one if they choose—but confirm what your plan materials say.