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.

Terms Used In Iowa Code 514J.110

  • 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
  • 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
  • Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
  • 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 services: includes dental care services. 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
  • provider: means a health care professional or a facility. See Iowa Code 514J.102
 2. a. A covered person or the covered person‘s authorized representative may appeal the external review decision made by an independent review organization by filing a petition for judicial review either in Polk county district court or in the district court in the county in which the covered person resides. The petition for judicial review must be filed within fifteen business days after the issuance of the review decision. The petition shall name the covered person or the covered person’s authorized representative, or the person’s health care provider as the petitioner. The respondent shall be the health carrier. The petition shall not name the independent review organization as a party.

 b. The commissioner shall not be named as a respondent unless the petitioner alleges action or inaction by the commissioner under the standards articulated in section 17A.19, subsection 10. Allegations against the commissioner under section 17A.19, subsection 10, shall be stated with particularity. The commissioner may, upon motion, intervene in the judicial review proceeding. The findings of fact by the independent review organization conducting the external review are conclusive and binding on appeal.
 3. The health carrier shall follow and comply with the decision of the court on appeal. The health carrier or treating health care provider shall not be subject to any penalties, sanctions, or award of damages for following and complying in good faith with the external review decision of the independent review organization or the decision of the court on appeal.
 4. The covered person or the covered person’s authorized representative may bring an action in Polk county district court or in the district court in the county in which the covered person resides to enforce the external review decision of the independent review organization or the decision of the court on appeal.
 5. A covered person or the covered person’s authorized representative shall not file a subsequent request for external review involving any determination for which the covered person or the covered person’s authorized representative has already received an external review decision.
 6. If a covered person dies before the completion of the external review process, the process shall continue to completion if there is potential liability of a health carrier to the estate of the covered person.
 7. a. If a covered person who has already received health care services under a health benefit plan requests external review of the plan’s adverse determination or final adverse determination and changes to another health benefit plan before the external review process is completed, the health carrier whose coverage was in effect at the time the health care service was received is responsible for completing the external review process.

 b. If a covered person who has not yet received health care services requests external review of a health benefit plan’s adverse determination or final adverse determination and then changes to another plan prior to receipt of the health care services and completion of the external review process, the external review process shall begin anew with the covered person’s current health carrier. In this instance, the external review process shall be conducted as an expedited external review.
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