§ 514J.110 — Effect of external review decision

Iowa § 514J.110

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

Text

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.
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
personorthecoveredperson’sauthorizedrepresentative, ortheperson’shealthcareprovider
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. Thehealthcarriershallfollowandcomplywiththedecisionofthecourtonappeal. 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
personresidestoenforcetheexternalreviewdecisionoftheindependentrevieworganization
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.