Terms Used In Iowa Code > Chapter 514J - External Review of Health Care Coverage Decisions

• 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
• benefits: means those health care services to which a covered person is entitled under the terms of a health benefit plan. See Iowa Code 514J.102
• Best evidence: means evidence based on randomized clinical trials. See Iowa Code 514J.102
• Board: means the engineering and land surveying examining board provided by this chapter. See Iowa Code 542B.2
• Certification: means a determination by a health carrier that an admission, availability of care, continued stay, or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness. 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
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• 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.
• Dental care services: means diagnostic, preventive, maintenance, and therapeutic dental care that is provided in accordance with chapter 153. See Iowa Code 514J.102
• Disclose: means to release, transfer, or otherwise divulge protected health information to any person other than the individual who is the subject of the protected health information. See Iowa Code 514J.102
• Emergency medical condition: means the sudden and, at the time, unexpected onset of a health condition or illness that requires immediate medical attention, where failure to provide medical attention would result in a serious impairment to bodily functions, serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. 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
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• Expert opinion: means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy. 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 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
• Health information: means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relates to any of the following:
   a. 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
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Medical or scientific evidence: means evidence found in any of the following sources:
   a. See Iowa Code 514J.102
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• 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
• Protected health information: means health information that meets either of the following descriptions:
   a. See Iowa Code 514J.102
• provider: means a health care professional or a facility. See Iowa Code 514J.102
• Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
• 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
• United States: includes all the states. See Iowa Code 4.1
• Uphold: The decision of an appellate court not to reverse a lower court decision.
• week: means seven consecutive days. See Iowa Code 4.1
• year: means twelve consecutive months. See Iowa Code 4.1