(And How Banjo Health Makes Compliance Seamless)
Colorado has taken meaningful steps to reduce administrative burdens and improve care access through its prior authorization (PA) regulations. Governed primarily by C.R.S. § 10-16-124.5 and C.R.S.§ 10-16-113, these rules directly impact how payers and PBMs handle authorizations for medical services and prescriptions.
If you're not already automating and optimizing your workflows, these regulations may leave you exposed to compliance risk, provider abrasion, and rising costs.
Here’s what Colorado requires—and how Banjo Health helps you get ahead.
Colorado's Prior Authorization Timeframes
Colorado mandates different response times based on urgency and request type:
● Medical Services:
○ Non-urgent: Response required within 15 calendar days
○ Urgent: Response required within 72 hours
● Pharmacy (Rx):
○ Electronic requests: Must be processed within 2 business days
○ Non-urgent oral/fax/email: Must be processed within 3 business days
○ Urgent: 1business day turnaround
These timelines can strain manual processes—Banjo’s real-time automation engine ensures every request is processed, escalated, and resolved on time.
ePA Requirements & Submission Standards
Colorado law encourages secure, web-based portals for PA submission and tracking. Health plans must accept electronic prior authorization (ePA) submissions and process them efficiently.
Banjo Health integrates seamlessly with provider workflows using the NCPDP SCRIPT standard, reducing friction and enabling true real-time determinations.
Colorado’s Clinical Criteria and Denial Rules
Health plans are required to use evidence-based clinical criteria for all determinations. When a request is denied:
● The rationale must be documented and provided to the provider
● Peer-to-peer review must be available within 5 calendar days
Banjo Health embeds up-to-date clinical guidelines into every ruleset and automates peer-matching for reviews, so your team stays compliant and providers stay satisfied.
Who Reviews PAs?
All prior authorization decisions must be reviewed by a licensed physician familiar with the standards of care in Colorado, especially for denials or appeals.
Banjo’s smart reviewer routing ensures escalations and appeals are always handled by the appropriate, credentialed specialists—helping you avoid regulatory missteps.
Colorado’s Prior Authorization Transparency &Disclosure Requirements
Payers must:
● Publish criteria and policies used in PA decisions
● Maintain and share a list of all drugs and services requiring PA
● Clearly communicate appeal rights and decisions
Banjo Health automatically tracks, logs, and makes this information accessible through configurable portals—ensuring total transparency with minimal administrative effort.
Consequences of Prior Authorization Non-Compliance in Colorado
Colorado enforces these rules strictly. Plans that fail to meet deadlines or transparency requirements can face:
● Regulatory penalties
● Delayed reimbursements
● Damaged provider relationships
Banjo Health = Instant Colorado Compliance
As regulations tighten, prior authorization can no longer be a manual, disconnected process. Banjo Health gives payers and PBMs:
● Intelligent automation for Colorado’s mandated timeframes
● Integrated ePA solutions
● Peer review routing and audit-ready logs
● Clinical criteria enforcement at scale
● Real-time reporting for regulators and stakeholders
