Under what conditions may health insurers legally deny claims in Colorado?

Health insurers in Colorado may legally deny claims primarily when the services claimed are not covered under the policy or when the required timelines for submission are not met. Insurance policies typically delineate explicitly what services are covered and under what circumstances claims must be submitted. If a claim involves a service that is outside of the agreed-upon terms of the health insurance policy, it is within the insurer's rights to deny payment.

Additionally, health insurance policies often establish specific time frames within which claims must be submitted. This is a critical aspect of the claims process. If a claim is submitted too late, it can lead to denial, as the insurer relies on timely reporting of claims to manage their risk and finance effectively.

In contrast, the other choices present scenarios that are either generally valid under many insurance policies or do not conform to standard practices. For example, preventive service coverage is typically mandated by law to be included without denial in many situations, especially those falling under essential health benefits. Claims submitted in paper format can still be processed, as insurers must accommodate various submission methods as long as the claim is valid. Similarly, while claims for out-of-network providers might be covered under certain policies, insurers cannot simply deny those claims outright; they must follow the terms set out in the