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 written notice of a final adverse determination.

Terms Used In Iowa Code 514J.104

  • 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 provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. See Iowa Code 514J.102
  • Authorized representative: means any of the following:
     a. See Iowa Code 514J.102
  • Commissioner: means the commissioner of insurance. See Iowa Code 514J.102
  • Covered person: means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. See Iowa Code 514J.102
  • Disclose: means to release, transfer, or otherwise divulge protected health information to any person other than the individual who is the subject of the protected health information. See Iowa Code 514J.102
  • Emergency services: means health care items and services furnished or required to evaluate and treat an emergency medical condition. See Iowa Code 514J.102
  • Facility: means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings. See Iowa Code 514J.102
  • Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health carrier at the completion of the health carrier's internal grievance process. See Iowa Code 514J.102
  • following: when used by way of reference to a chapter or other part of a statute mean the next preceding or next following chapter or other part. See Iowa Code 4.1
  • Health care professional: means a physician or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law. See Iowa Code 514J.102
  • Health carrier: means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance company offering sickness and accident plans, a health maintenance organization, a nonprofit health service corporation, a plan established pursuant to chapter 509A for public employees, or any other entity providing a plan of health insurance, health care benefits, or health care services. See Iowa Code 514J.102
  • Health information: means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relates to any of the following:
     a. See Iowa Code 514J.102
  • Person: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. See Iowa Code 514J.102
  • provider: means a health care professional or a facility. See Iowa Code 514J.102
  • Rule: includes "regulation". See Iowa Code 4.1
 2. a. The notice shall include the following, or substantially equivalent, language:

 We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested by submitting a request for external review to the commissioner of insurance.
 b. The notice shall include the current address and contact information for the commissioner as specified in administrative rule.
 3. The health carrier shall include in the notice a statement informing the covered person or the covered person’s authorized representative, if known, of the following:

 a. If the covered person has a medical condition pursuant to which the time frame for completion of a standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or the covered person’s authorized representative may file a request for an expedited external review.
 b. If the final adverse determination concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services, but has not been discharged from a facility, the covered person or the covered person’s authorized representative may request an expedited external review.
 c. If the final adverse determination concerns a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational as provided in section 514J.109, the covered person may file a request for external review pursuant to section 514J.109. In addition, if the covered person’s treating health care professional certifies in writing that the recommended or requested health care service or treatment that is the subject of the recommendation or request would be significantly less effective if not promptly initiated, the covered person or the covered person’s authorized representative may request an expedited external review pursuant to section 514J.109, subsection 18.
 4. The health carrier shall include with the notice a copy of the descriptions of both the standard and expedited external review procedures the health carrier is required to provide pursuant to section 514J.116, highlighting the provisions in the external review procedures that give the covered person or the covered person’s authorized representative the opportunity to submit additional information and including any forms used to process an external review.
 5. The health carrier shall also include with the notice an authorization form, or other document approved by the commissioner that complies with the requirements of 45 C.F.R. §164.508 and with Tit. I of the federal Genetic Information Nondiscrimination Act of 2008, Pub. L. No. 110-233, 122 Stat. 881, by which the covered person or the covered person’s authorized representative authorizes the health carrier and the covered person’s treating health care provider to disclose protected health information, including medical records, concerning the covered person that is pertinent to the external review.
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