Section 514J.1 – Legislative intent.
514J.1 Legislative intent. Repealed by 2011 Acts, ch 101, §21 .
Section 514J.10 – Reporting.
514J.10 Reporting. Repealed by 2011 Acts, ch 101, §21.
Section 514J.101 – Purpose — applicability.
514J.101 Purpose — applicability. The purpose of this chapter is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination made by a health carrier as required by the federal Patient Protection […]
Section 514J.102 – Definitions.
514J.102 Definitions. As used in this chapter, unless the context otherwise requires: 1. a. “Adverse determination” means a determination by a health carrier that an admission, availability of care, continued stay, or other health care service, other than a dental care service, that is a covered benefit has been reviewed and, based upon the information […]
Section 514J.103 – Applicability and scope.
514J.103 Applicability and scope. 1. Except as provided in subsection 2, this chapter shall apply to all health carriers. 2. This chapter shall not apply to any of the following: a. A policy or certificate that provides coverage only for a specified disease, specified accident or accident-only, credit, disability income, hospital indemnity, long-term care, vision […]
Section 514J.104 – Notice of right to external review.
514J.104 Notice of right to external review. 1. A health carrier shall notify a covered person or the covered person’s authorized representative, if known, in writing of the covered person’s right to request an external review and include the appropriate statements and information set forth in this chapter at the time the health carrier sends […]
Section 514J.105 – Request for external review.
514J.105 Request for external review. A covered person or the covered person’s authorized representative may make a request for an external review of a final adverse determination. Except for a request for an expedited external review, all requests for external review shall be made in writing to the commissioner. The commissioner may prescribe by rule […]
Section 514J.106 – Exhaustion of internal grievance process — exceptions — expedited external review request.
514J.106 Exhaustion of internal grievance process — exceptions — expedited external review request. 1. Except as otherwise provided in this section, a request for an external review shall not be made until the covered person or the covered person’s authorized representative has exhausted the health carrier’s internal grievance process and received a final adverse determination. […]
Section 514J.107 – External review — standard.
514J.107 External review — standard. 1. A covered person or the covered person’s authorized representative may file a written request for an external review with the commissioner within four months after any of the following events: a. The date of receipt of a final adverse determination. b. The failure of a health carrier to issue […]
Section 514J.108 – External review — expedited.
514J.108 External review — expedited. 1. Notwithstanding section 514J.107, a covered person or the covered person’s authorized representative may make an oral or written request to the commissioner for an expedited external review at the time the covered person or the covered person’s authorized representative receives any of the following: a. An adverse determination that […]
Section 514J.109 – External review of experimental or investigational treatment adverse determinations.
514J.109 External review of experimental or investigational treatment adverse determinations. 1. Within four months after the date of receipt of a notice of an adverse determination or final adverse determination that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a […]
Section 514J.11 – Immunity.
514J.11 Immunity. Repealed by 2011 Acts, ch 101, §21.
Section 514J.110 – Effect of external review decision.
514J.110 Effect of external review decision. 1. An external review decision pursuant to this chapter is binding on the health carrier except to the extent the health carrier has other remedies available under applicable Iowa law. The external review process shall not be considered a contested case under chapter 17A. 2. a. A covered person […]
Section 514J.111 – Approval of independent review organizations.
514J.111 Approval of independent review organizations. 1. The commissioner shall approve applications submitted by independent review organizations to conduct external reviews under this chapter. The commissioner may retain an outside expert to perform reviews of such applications. 2. In order to be eligible for approval by the commissioner to conduct external reviews, an independent review […]
Section 514J.112 – Minimum qualifications for independent review organizations.
514J.112 Minimum qualifications for independent review organizations. 1. To be approved to conduct external reviews pursuant to this chapter, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process and that include, at a minimum, all […]
Section 514J.113 – Immunity for independent review organizations.
514J.113 Immunity for independent review organizations. An independent review organization, a clinical reviewer working on behalf of an independent review organization, or an employee, agent, or contractor of an independent review organization shall not be liable in damages to any person for any opinions rendered or acts or omissions performed within the scope of the […]
Section 514J.114 – External review reporting requirements.
514J.114 External review reporting requirements. 1. a. An independent review organization assigned to conduct an external review shall maintain written records in the aggregate by state and by health carrier of all requests for external review for which it conducted an external review during a calendar year. b. Each independent review organization required to maintain […]
Section 514J.115 – Expenses of external review.
514J.115 Expenses of external review. The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the costs of retaining an independent review organization to conduct the external review. 2011 Acts, ch 101, §15
Section 514J.116 – Disclosure requirements.
514J.116 Disclosure requirements. 1. Each health carrier shall include a description of the external review procedures contained in this chapter in or attached to any policy, certificate, membership booklet, outline of coverage, or other evidence of coverage that is provided to a covered person. The description shall be in a format prescribed by the commissioner […]
Section 514J.117 – Rulemaking authority.
514J.117 Rulemaking authority. The commissioner may adopt rules pursuant to chapter 17A to carry out the provisions of this chapter. 2011 Acts, ch 101, §17