Terms Used In Iowa Code 514J.114

• 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
• 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 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
• state: when applied to the different parts of the United States, includes the District of Columbia and the territories, and the words "United States" may include the said district and territories. See Iowa Code 4.1
• year: means twelve consecutive months. See Iowa Code 4.1