Iowa Code 514J.105 – Request for external review
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Terms Used In Iowa Code 514J.105
- 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
- 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
- Rule: includes "regulation". See Iowa Code 4.1
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 the form and content of external review requests.