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 involves a medical condition of the covered person for which the time frame for completion of an internal review of a 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.
 b. A final adverse determination that involves a medical condition where 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.
 c. A final adverse determination that concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services, and the covered person has not been discharged from a facility.

Terms Used In Iowa Code 514J.108

  • 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
  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Authorized representative: means any of the following:
     a. See Iowa Code 514J.102
  • Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services. 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
  • 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 benefit plan: means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. See Iowa Code 514J.102
  • 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
  • Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. 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
  • Uphold: The decision of an appellate court not to reverse a lower court decision.
 2. a. Upon receipt of a request for an expedited external review, the commissioner shall immediately send written notice of the request to the health carrier.

 b. Immediately upon receipt of notice of a request for expedited external review, the health carrier shall complete a preliminary review of the request to determine whether the request meets the eligibility requirements for external review set forth in section 514J.107, subsection 3, and this section.
 c. The health carrier shall then immediately issue a notice of initial determination informing the commissioner and the covered person or the covered person’s authorized representative of its eligibility determination including a statement informing the covered person or the covered person’s authorized representative of the right to appeal that determination to the commissioner.
 d. The commissioner may specify by rule the form required for the health carrier’s notice of initial determination and any supporting information to be included in the notice.
 3. The commissioner may determine that a request is eligible for expedited external review, notwithstanding a health carrier’s initial determination that the request is not eligible. In making a determination, the commissioner’s decision shall be made in accordance with the terms of the covered person’s health benefit plan and shall be subject to all applicable provisions of this chapter. The commissioner shall make a determination pursuant to this subsection as expeditiously as possible.
 4. a. Upon receipt of notice from a health carrier that a request is eligible for expedited external review or upon a determination by the commissioner that a request is eligible for expedited external review, the commissioner shall immediately assign an independent review organization from the list of approved independent review organizations maintained by the commissioner to conduct the expedited external review. The commissioner shall then immediately notify the health carrier and the covered person or the covered person’s authorized representative of the name of the assigned independent review organization.

 b. The assignment of an independent review organization shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the health care service that is the subject of the adverse determination or final adverse determination and other circumstances, including conflict of interest concerns.
 5. Upon receiving notice of the independent review organization assigned to conduct the expedited external review, the health carrier shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the independent review organization electronically or by telephone or facsimile or any other available expeditious method.
 6. The independent review organization is not bound by any decisions or conclusions reached during the health carrier’s internal grievance process. The independent review organization shall consider the documents and information provided by the health carrier, and to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision:

 a. The covered person’s pertinent medical records.
 b. The treating health care professional‘s recommendation.
 c. Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person or the covered person’s authorized representative, or the covered person’s treating physician or other health care professional.
 d. The terms of coverage under the covered person’s health benefit plan with the health carrier, to ensure that the independent review organization’s decision is not contrary to the terms of coverage under the covered person’s health benefit plan with the health carrier.
 e. The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or professional medical societies, boards, and associations.
 f. Any applicable clinical review criteria developed and used by the health carrier.
 g. The opinion of the independent review organization’s clinical reviewer after considering the information or documents described in paragraphs “a” through “f” to the extent the information or documents are available and the clinical reviewer considers them relevant.
 7. a. As expeditiously as the covered person’s medical condition or circumstances require, but in no event more than seventy-two hours after the date of receipt of an eligible request for expedited external review, the assigned independent review organization shall do all of the following:

 (1) Make a decision to uphold or reverse the adverse determination or final adverse determination of the health carrier.
 (2) Notify the covered person or the covered person’s authorized representative, the health carrier, and the commissioner of its decision.
 b. If the notice given by the independent review organization pursuant to paragraph “a” was not in writing, within forty-eight hours after providing that notice, the independent review organization shall provide written confirmation of the decision to the covered person or the covered person’s authorized representative, the health carrier, and the commissioner that includes the information set forth in section 514J.107, subsection 13, paragraph “b”.
 c. Upon receipt of the notice of decision by an independent review organization pursuant to paragraph “a” reversing the adverse determination or final adverse determination, the health carrier shall immediately approve the coverage that was the subject of the adverse determination or final adverse determination.
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