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.

Terms Used In Iowa Code 514J.106

  • 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
  • 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 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
  • 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
 2. A covered person or the covered person’s authorized representative shall be considered to have exhausted the health carrier’s internal grievance process if the covered person or the covered person’s authorized representative has filed a grievance involving an adverse determination and, except to the extent the covered person or the covered person’s authorized representative requested or agreed to a delay, has not received a written decision on the grievance from the health carrier within thirty days following the date the covered person or the covered person’s authorized representative filed the grievance with the health carrier.
 3. A covered person or the covered person’s authorized representative may file a request for an expedited external review of an adverse determination without exhausting the health carrier’s internal grievance process under either of the following circumstances:

 a. The covered person has a medical condition pursuant to which the time frame for completion of an internal review of the grievance involving an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function as provided in section 514J.108.
 b. The adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated as provided in section 514J.109.
 4. A request for an external review of an adverse determination may be made before the covered person or the covered person’s authorized representative has exhausted the health carrier’s internal grievance procedures whenever the health carrier agrees to waive the exhaustion requirement. If the requirement to exhaust the health carrier’s internal grievance procedures is waived, the covered person or the covered person’s authorized representative may file a request with the commissioner in writing for a standard external review.
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