§ 514J.107 — External review — standard

Iowa § 514J.107

• Jurisdiction: Iowa
• Title XIII: COMMERCE
• Ch. 514J: EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS

Text

1. A covered person or the covered person’s authorized representative may file a written
request for an external review with the commissioner within four months after any of the
following events:
a. The date of receipt of a final adverse determination.
b. Thefailureofahealthcarriertoissueawrittendecisionwithinthirtydaysfollowingthe
date the covered person or the covered person’s authorized representative filed a grievance
involving an adverse determination as provided in section 514J.106, subsection 2.
c. Theagreementofthehealthcarriertowaivetherequirementthatthecoveredpersonor
thecoveredperson’sauthorizedrepresentativeexhaustthehealthcarrier’sinternalgrievance
proceduresbeforefilingarequestforexternalreviewofanadversedeterminationasprovided
in section 514J.106, subsection 4.
2. Within one business day after the date of receipt of a request for external review, the
commissioner shall send a copy of the request to the health carrier.
3. Within five business days following the date of receipt of the external review request
from the commissioner, the health carrier shall complete a preliminary review of the request
to determine whether:
a. The individual is or was a covered person under the health benefit plan at the time the
health care service was recommended or requested.
b. The health care service that is the subject of the adverse determination or of the final
adversedeterminationisacoveredserviceunderthecoveredperson’shealthbenefitplan, but
for a determination by the health carrier that the health care service is not covered because
it does not meet the health carrier’s requirements for medical necessity, appropriateness,
health care setting, level of care, or effectiveness.
c. The covered person or the covered person’s authorized representative has exhausted
the health carrier’s internal grievance process, unless the covered person or the covered
person’s authorized representative is not required to exhaust the health carrier’s internal
grievance process pursuant to section 514J.106 or this section.
d. The covered person or the covered person’s authorized representative has provided all
the information and forms required to process an external review request.
4. Within one business day after completion of a preliminary review pursuant to
subsection 3, the health carrier shall notify the commissioner and the covered person or the
covered person’s authorized representative in writing whether the request is complete and
whether the request is eligible for external review.
a. If the health carrier determines that the request is not complete, the health carrier
shall notify the covered person or the covered person’s authorized representative and the
commissioner in writing that the request is not complete and what information or materials
are needed to make the request complete.
b. If the health carrier determines that the request is not eligible for external review, the
health carrier shall issue a notice of initial determination in writing informing the covered
person or the covered person’s authorized representative and the commissioner of that
determination and the reasons the request is not eligible for review. The health carrier shall
also include a statement in the notice informing the covered person or the covered person’s
authorized representative that the health carrier’s initial determination of ineligibility may
be appealed to the commissioner.
7 EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS, §514J.107
5. 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.
6. The commissioner may determine that a request is eligible for external review,
notwithstanding a health carrier’s initial determination that the request is not eligible, and
refer the request for external review. In making this 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.
7. Within one business day after receipt of notice from a health carrier that a request for
external review is eligible for external review or upon a determination by the commissioner
that a request is eligible for external review, the commissioner shall do all of the following:
a. Assign an independent review organization from the list of approved independent
review organizations maintained by the commissioner and notify the health carrier of the
name of the assigned independent review organization. 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.
b. Notify the covered person or the covered person’s authorized representative in
writing that the request is eligible and has been accepted for external review including
the name of the assigned independent review organization and that the covered person or
the covered person’s authorized representative may submit in writing to the independent
review organization within five business days following receipt of such notice from the
commissioner, additional information that the independent review organization shall
consider when conducting the external review. The independent review organization may,
in the organization’s discretion, accept and consider additional information submitted by the
covered person or the covered person’s authorized representative after five business days.
8. Within five business days after receipt of notice from the commissioner pursuant
to subsection 7, the health carrier shall provide to the independent review organization
the documents and any information considered in making the adverse determination or
final adverse determination. Failure by the health carrier to provide the documents and
information within the time specified shall not delay the conduct of the external review.
9. If the health carrier fails to provide the documents and information within the time
specified, the independent review organization may terminate the external review and make
a decision to reverse the adverse determination or final adverse determination. Within one
business day after making such a decision, the independent review organization shall notify
the covered person or the covered person’s authorized representative, the health carrier, and
the commissioner of its decision.
10. The independent review organization shall review all of the information and
documents received pursuant to subsection 8 and any other information submitted in
writing to the independent review organization by the covered person or the covered
person’s authorized representative pursuant to subsection 7, paragraph “b”. Upon receipt
of any information submitted by the covered person or the covered person’s authorized
representative, the independent review organization shall, within one business day, forward
the information to the health carrier. In reaching a decision the independent review
organization is not bound by any decisions or conclusions reached during the health carrier’s
internal grievance process.
11. Uponreceiptofinformationforwardedpursuanttosubsection10,ahealthcarriermay
reconsider its adverse determination or final adverse determination that is the subject of the
external review.
a. Reconsideration by the health carrier of its determination shall not delay or terminate
theexternalreview. Theexternalreviewshallonlybeterminatedifthehealthcarrierdecides,
upon completion of its reconsideration, to reverse its determination and provide coverage or
payment for the health care service that is the subject of the adverse determination or final
adverse determination.
b. Within one business day after making a decision to reverse its adverse determination
or final adverse determination, the health carrier shall notify the covered person or the
§514J.107, EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS 8
covered person’s authorized representative, the independent review organization, and
the commissioner in writing of its decision. The independent review organization shall
terminate the external review upon receipt of notice of the health carrier’s decision to
reverse its adverse determination or final adverse determination.
12. In addition to the documents and information provided to the independent review
organization pursuant to this section, the independent review organization shall, to the
extent the information or documents are available and the independent review organization
considers them appropriate, 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 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.
13. a. Within forty-five days after the date of receipt of a request for an external review,
the independent review organization shall provide written notice of its decision to uphold or
reverse the adverse determination or final adverse determination of the health carrier to the
covered person or the covered person’s authorized representative, the health carrier, and the
commissioner.
b. The independent review organization shall include in its decision all of the following:
(1) A general description of the reason for the request for external review.
(2) The date the independent review organization received the assignment from the
commissioner to conduct the external review.
(3) The date the external review was conducted.
(4) The date of the decision.
(5) The principal reason or reasons for its decision, including what applicable
evidence-based standards, if any, were a basis for its decision.
(6) The rationale for its decision.
(7) References to evidence or documentation, including evidence-based standards,
considered in reaching its decision.
14. Upon receipt of notice of a decision reversing the adverse determination or final
adverse determination of the health carrier, the health carrier shall immediately approve the
coverage that was the subject of the determination.