Text: HSB00243 Text: HSB00245 Text: HSB00200 - HSB00299 Text: HSB Index Bills and Amendments: General Index Bill History: General Index
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1 1 Section 1. NEW SECTION. 514J.1 INTENT OF THE GENERAL
1 2 ASSEMBLY.
1 3 It is the intent of the general assembly that certain
1 4 assurances be established relating to the relationship of
1 5 patients and health care providers with health plans doing
1 6 business in this state. It is also the intent of the general
1 7 assembly to provide a mechanism for the appeal of a denial of
1 8 coverage based upon medical necessity. Additionally, it is
1 9 the intent of the general assembly that patients and health
1 10 care providers receive the reimbursements to which they are
1 11 entitled in a timely manner in order to reduce or eliminate
1 12 unnecessary and costly delays.
1 13 Sec. 2. NEW SECTION. 514J.2 DEFINITIONS.
1 14 1. "Carrier" means an entity subject to the insurance laws
1 15 and regulations of this state, or subject to the jurisdiction
1 16 of the commissioner, performing utilization review, including
1 17 an insurance company offering sickness and accident plans, a
1 18 health maintenance organization, a preferred provider
1 19 arrangement, a multiple employer welfare arrangement, a third-
1 20 party administrator, a fraternal benefit society, a nonprofit
1 21 health service corporation, a plan established pursuant to
1 22 chapter 509A for public employees, or any other entity
1 23 providing a plan of health insurance, health care benefits, or
1 24 health care services that conducts utilization review.
1 25 "Carrier" does not mean a hospital confinement indemnity,
1 26 credit, dental, vision, long-term care, or disability income
1 27 insurance coverage, coverage issued as a supplement to
1 28 liability insurance, workers' compensation or similar
1 29 insurance, or automobile medical payment insurance unless such
1 30 an entity conducts utilization review.
1 31 2. "Clean health insurance claim" means and includes, but
1 32 is not limited to, a claim that is submitted on a carrier's or
1 33 organized delivery system's standard claim form, does not
1 34 contain attachments, and does not require additional
1 35 information to process the claim.
2 1 3. "Commissioner" means the commissioner of insurance.
2 2 4. "Coverage decision" means a final decision by a carrier
2 3 or organized delivery system based on medical necessity. This
2 4 definition does not include a denial of coverage for health
2 5 care services specifically listed in plan or evidence of
2 6 coverage documents as excluded from coverage.
2 7 5. "Emergency medical condition" means a medical condition
2 8 which manifests itself by symptoms of sufficient severity,
2 9 including but not limited to severe pain, such that an
2 10 ordinary prudent layperson, who possesses an average knowledge
2 11 of health and medicine, could reasonably expect the absence of
2 12 immediate medical attention to result in one of the following:
2 13 a. Placing the health of the individual or, with respect
2 14 to a pregnant woman, the health of the woman or the fetus, in
2 15 serious jeopardy.
2 16 b. Serious impairment to bodily functions.
2 17 c. Serious dysfunction of any bodily organ or part.
2 18 6. "Emergency services" means covered inpatient and
2 19 outpatient services that are furnished by a health care
2 20 provider who is qualified to furnish such services needed to
2 21 evaluate or stabilize an emergency medical condition.
2 22 7. "Enrollee" means an individual, or an eligible
2 23 dependent, who receives health care services coverage through
2 24 a carrier or organized delivery system.
2 25 8. "Health care professional" means a person licensed to
2 26 or certified to practice a profession as defined in section
2 27 147.1 and who provides health care services.
2 28 9. "Health care provider" means an individual licensed or
2 29 certified to provide professional health care services to a
2 30 person during the person's medical care, treatment, or
2 31 confinement consistent with state law.
2 32 10. "Health care services" means services included in the
2 33 furnishing to any individual of medical or dental care, or
2 34 hospitalization, or incident to the furnishing of such care or
2 35 hospitalization, as well as furnishing to any person of all
3 1 other services for the purposes of preventing, alleviating,
3 2 caring, or healing human illness, injury, or physical
3 3 disability.
3 4 11. "Independent review entity" means a reviewer or
3 5 entity, certified by the commissioner pursuant to section
3 6 514J.7.
3 7 12. "Medical necessity" means health care services or
3 8 products that a prudent health care provider would provide to
3 9 a patient to prevent, diagnose, or treat an illness, injury,
3 10 or disease or its symptoms, in a manner which is in accordance
3 11 with generally accepted standards of practice, is clinically
3 12 appropriate, and is not primarily for the convenience of the
3 13 patient or the health care provider.
3 14 13. "Organized delivery system" means an organized
3 15 delivery system authorized under 1993 Iowa Acts, chapter 158,
3 16 and licensed by the director of public health, and performing
3 17 utilization review.
3 18 14. "Participating" means, with respect to a health care
3 19 professional or health care provider, entering into an
3 20 agreement or arrangement with a carrier or organized delivery
3 21 system to provide health care services to enrollees.
3 22 15. "Physician" means a person licensed to practice
3 23 medicine and surgery pursuant to chapter 148 or osteopathic
3 24 medicine and surgery pursuant to chapter 150.
3 25 16. "Utilization review" and "utilization review program"
3 26 mean procedures and processes used to evaluate the clinical
3 27 necessity, appropriateness, efficacy, or efficiency of health
3 28 care services, procedures, or settings, and includes
3 29 prospective review, concurrent review, second opinions, case
3 30 management, discharge planning, or retrospective review.
3 31 "Utilization review" does not mean an evaluation of requests
3 32 by an enrollee or health care provider for a clarification,
3 33 guarantee, or statement of an individual's health insurance
3 34 coverage or health care service benefits provided under a
3 35 health insurance policy, or claims adjudication. Unless it is
4 1 specifically stated, verification of benefits, prior
4 2 authorization, or a prospective or concurrent utilization
4 3 review program or process shall not be construed as a
4 4 guarantee or statement of insurance coverage or benefits under
4 5 a health insurance policy.
4 6 Sec. 3. NEW SECTION. 514J.3 UTILIZATION REVIEW
4 7 REQUIREMENTS.
4 8 1. A carrier or organized delivery system which provides
4 9 health care services benefits to enrollees residing in this
4 10 state shall not conduct any utilization review either directly
4 11 or indirectly under a contract with a third party, and must
4 12 meet the requirements established for accreditation by the
4 13 utilization review accreditation commission, national
4 14 commission on quality assurance, or another national
4 15 accreditation entity recognized and approved by the
4 16 commissioner.
4 17 2. Utilization review shall be conducted by a carrier or
4 18 organized delivery system consistent with written policies and
4 19 procedures that govern all aspects of the utilization review
4 20 program.
4 21 3. A utilization review program shall be conducted only
4 22 through personnel who are qualified and appropriately trained
4 23 in the performance of utilization review functions, shall be
4 24 based on information requested from the enrollee and the
4 25 enrollee's treating health care provider which is adequate to
4 26 make an informed decision, shall take into account factors
4 27 unique to the enrollee's health care needs and the
4 28 availability of health care providers and services to meet
4 29 those needs within reasonable geographic proximity to the
4 30 enrollee, and shall give deference to the treating health care
4 31 provider's recommendations for care in making medical
4 32 necessity determinations.
4 33 4. A utilization review program shall not provide for the
4 34 performance of utilization review with respect to a class of
4 35 services furnished to an individual more frequently than is
5 1 reasonably required to assess whether the services under
5 2 review are medically necessary or appropriate.
5 3 5. A utilization review program shall assure that a
5 4 coverage decision based on medical necessity is made only upon
5 5 review by or consultation with a health care provider licensed
5 6 and actively practicing in this state and, where specialty
5 7 services are under review, by health care providers licensed
5 8 and actively practicing in the same specialty.
5 9 6. A utilization review program shall be conducted under
5 10 the direction of a physician holding an unrestricted license
5 11 to practice medicine and surgery under chapter 148 or a
5 12 physician holding an unrestricted license to practice
5 13 osteopathic medicine and surgery under chapter 150A.
5 14 7. A utilization review program shall utilize specific
5 15 written clinical criteria that are based on sound scientific
5 16 and clinical principles and processes, developed in
5 17 consultation with physicians and other health care providers
5 18 as appropriate, evaluated at least annually, and disclosed to
5 19 the enrollee and health care provider upon request following
5 20 coverage decision.
5 21 8. Information obtained from the enrollee and the
5 22 enrollee's treating health care provider shall be kept
5 23 confidential, shall be used solely for the purpose of
5 24 utilization review of the health care service under review,
5 25 shall be limited only to that information which is necessary
5 26 for conducting the review, and shall be shared only with
5 27 persons who have authority to receive and have a need for the
5 28 information in conducting utilization review.
5 29 9. If a health care service has been specifically
5 30 preauthorized or approved for an enrollee, that health care
5 31 service shall not be denied retrospectively by utilization
5 32 review based on subsequently adopted or revised standards,
5 33 criteria, or processes for utilization review.
5 34 10. This section does not apply to any utilization review
5 35 performed solely under contract with the federal government
6 1 for review of patients eligible for services under any of the
6 2 following:
6 3 a. Title XVIII of the federal Social Security Act.
6 4 b. The civilian health and medical program of the
6 5 uniformed services.
6 6 c. Any other federal employee health benefit plan.
6 7 Sec. 4. NEW SECTION. 514J.4 EXCLUSIONS.
6 8 This chapter does not apply to a hospital confinement
6 9 indemnity, credit, dental, vision, long-term care, or
6 10 disability income insurance coverage, coverage issued as a
6 11 supplement to liability insurance, workers' compensation or
6 12 similar insurance, or automobile medical payment insurance.
6 13 Sec. 5. NEW SECTION. 514J.5 EXTERNAL REVIEW REQUEST.
6 14 1. At the time of a coverage decision, the carrier or
6 15 organized delivery system shall notify the enrollee of the
6 16 right to have the coverage decision reviewed under an external
6 17 review process.
6 18 2. The enrollee, or the enrollee's treating health care
6 19 provider acting on behalf of the enrollee, may file a written
6 20 request for external review of the coverage decision with the
6 21 commissioner. The request must be filed within sixty days of
6 22 the receipt of the coverage decision.
6 23 3. The request for external review must be accompanied by
6 24 a twenty-five dollar filing fee. The commissioner may waive
6 25 the filing fee for good cause. The filing fee shall be
6 26 refunded if the enrollee prevails in the external review
6 27 process.
6 28 Sec. 6. NEW SECTION. 514J.6 ELIGIBILITY.
6 29 1. The commissioner shall have two business days from
6 30 receipt of a request for an external review to certify the
6 31 request. The commissioner shall certify the review request if
6 32 all of the following criteria are satisfied:
6 33 a. The enrollee was covered by the carrier or organized
6 34 delivery system at the time the health care service was
6 35 proposed or the coverage decision was requested.
7 1 b. The enrollee has been denied coverage based on a
7 2 determination by the carrier or organized delivery system that
7 3 the proposed health care service does not meet the definition
7 4 of medical necessity as defined in the enrollee's evidence of
7 5 coverage and is not specifically excluded under the evidence
7 6 of coverage.
7 7 c. The enrollee, or the enrollee's treating health care
7 8 provider acting on behalf of the enrollee, has exhausted all
7 9 internal appeal mechanisms provided under the carrier's or the
7 10 organized delivery system's contract.
7 11 d. The written request for external review was filed
7 12 within sixty days of receipt of the coverage decision.
7 13 2. The commissioner shall notify the enrollee, or the
7 14 enrollee's treating health care provider acting on behalf of
7 15 the enrollee, and the carrier or organized delivery system, in
7 16 writing, of the decision to certify or not to certify the
7 17 request.
7 18 3. The carrier or organized delivery system has three days
7 19 to contest the eligibility of the request for external review
7 20 with the commissioner. If the commissioner finds that the
7 21 request for external review is not eligible for full review,
7 22 the commissioner shall notify the enrollee, or the enrollee's
7 23 treating health care provider acting on behalf of the
7 24 enrollee, in writing, that the request for external review is
7 25 not eligible for full review and the reasons for
7 26 ineligibility.
7 27 Sec. 7. NEW SECTION. 514J.7 INDEPENDENT REVIEW ENTITIES.
7 28 1. The commissioner shall solicit names of independent
7 29 review entities from carriers, organized delivery systems, and
7 30 medical professional associations.
7 31 2. Independent review entities may include all of the
7 32 following:
7 33 a. Medical peer review organizations.
7 34 b. Nationally recognized health experts or institutions.
7 35 3. The commissioner shall certify independent review
8 1 entities to conduct external reviews. An individual who
8 2 conducts an external review as or as part of a certified
8 3 independent review entity shall be a health care professional
8 4 or health care provider and shall satisfy all of the following
8 5 requirements:
8 6 a. Hold a current unrestricted license to practice
8 7 medicine or a health profession in the United States. A
8 8 health care professional or health care provider who is a
8 9 physician shall also hold a current certification by a
8 10 recognized American medical specialty board.
8 11 b. Have no history of disciplinary actions or sanctions,
8 12 including, but not limited to, the loss of staff privileges or
8 13 any participation restriction taken or pending by any hospital
8 14 or state or federal government regulatory agency.
8 15 4. Each independent review entity shall file a quality
8 16 assurance program with the commissioner that ensures the
8 17 timeliness and quality of the reviews, the qualifications and
8 18 independence of the experts, and the confidentiality of
8 19 medical records and review materials.
8 20 5. The commissioner shall certify independent review
8 21 entities every two years.
8 22 Sec. 8. NEW SECTION. 514J.8 EXTERNAL REVIEW.
8 23 The external review process shall meet all of the following
8 24 criteria:
8 25 1. The carrier or organized delivery system, within three
8 26 business days of a receipt of an eligible request for an
8 27 external review from the commissioner, shall do all of the
8 28 following:
8 29 a. Select an independent review entity from the list
8 30 certified by the commissioner. The independent review entity
8 31 shall be an expert in the treatment of the medical condition
8 32 under review. The independent review entity shall not be
8 33 under contract with, be a subsidiary of, or be owned or
8 34 controlled by, the carrier or organized delivery system, or be
8 35 owned or controlled by a trade association of carriers or
9 1 organized delivery systems of which the carrier or organized
9 2 delivery system is a member.
9 3 b. Notify the enrollee, and the enrollee's treating health
9 4 care provider, of the name, address, and phone number of the
9 5 independent review entity and of the enrollee's and treating
9 6 health care provider's right to submit additional information.
9 7 c. Provide any information submitted to the carrier or
9 8 organized delivery system by the enrollee or the enrollee's
9 9 treating health care provider in support of the request for
9 10 coverage of a service or treatment under the carrier's or
9 11 organized delivery system's appeal procedures.
9 12 d. Provide any other relevant documents used by the
9 13 carrier or organized delivery system in determining whether
9 14 the proposed health care service should have been provided.
9 15 2. The enrollee, or the enrollee's treating health care
9 16 provider, may object to the independent review entity selected
9 17 by the carrier or organized delivery system. The objection
9 18 shall be made to the commissioner within two business days of
9 19 notification by the carrier or organized delivery system of
9 20 the name of the independent review entity. The enrollee, or
9 21 the enrollee's treating health care provider, shall notify the
9 22 commissioner in writing of the objection and the reason for
9 23 the objection. The commissioner shall select the independent
9 24 review entity, which may be the same independent review entity
9 25 selected by the carrier or organized delivery system, within
9 26 two business days of receipt of the written objection. The
9 27 commissioner shall notify the enrollee, or the enrollee's
9 28 treating health care provider, and the carrier or organized
9 29 delivery system of the name of the independent review entity
9 30 selected.
9 31 3. The enrollee, or the enrollee's treating health care
9 32 provider, may provide any information submitted in support of
9 33 the internal review and other newly discovered relevant
9 34 information. The enrollee or the enrollee's treating health
9 35 care provider shall have ten days from the mailing date of the
10 1 notification of the independent review entity's selection to
10 2 provide this information. Failure to provide the information
10 3 within ten days shall be grounds for rejection of
10 4 consideration of the information by the independent review
10 5 entity.
10 6 4. The independent review entity, within five business
10 7 days of receipt of the documentation required under subsection
10 8 1, shall notify the enrollee and the enrollee's treating
10 9 health care provider of any additional medical information
10 10 required to conduct the review. The requested information
10 11 shall be submitted within five days. Failure to provide the
10 12 information with good cause shall be grounds for rejection of
10 13 consideration of the information by the independent review
10 14 entity. The carrier or organized delivery system shall be
10 15 notified of this request.
10 16 5. The independent review entity shall submit its decision
10 17 as soon as possible, but not more than thirty days from the
10 18 independent review entity's receipt of the request for review.
10 19 The decision shall be mailed to the enrollee, or the treating
10 20 health care provider acting on behalf of the enrollee, and the
10 21 carrier or organized delivery system.
10 22 6. The confidentiality of any medical records submitted
10 23 shall be maintained pursuant to applicable state and federal
10 24 laws.
10 25 Sec. 9. NEW SECTION. 514J.9 EXPEDITED REVIEW.
10 26 An expedited review shall be conducted within seventy-two
10 27 hours of receipt of a request for external review by the
10 28 commissioner if the enrollee's treating health care provider
10 29 states that delay would pose an imminent or serious threat to
10 30 the life or health of the enrollee.
10 31 Sec. 10. NEW SECTION. 514J.10 FUNDING.
10 32 All reasonable fees and costs of the independent review
10 33 entity in conducting an external review shall be paid by the
10 34 carrier or organized delivery system.
10 35 Sec. 11. NEW SECTION. 514J.11 REPORTING.
11 1 Each carrier and organized delivery system shall file an
11 2 annual report with the commissioner containing all of the
11 3 following:
11 4 1. The number of external reviews requested.
11 5 2. The number of the external reviews certified by the
11 6 commissioner.
11 7 3. The number of coverage decisions which were upheld
11 8 through external review.
11 9 The commissioner shall compile the reports filed by January
11 10 31 of each year.
11 11 Sec. 12. NEW SECTION. 514J.12 IMMUNITY.
11 12 An independent review entity conducting a review under this
11 13 chapter is not liable for damages arising from determinations
11 14 made under the review process. This does not apply to any act
11 15 or omission by the independent review entity made in bad faith
11 16 or involving gross negligence.
11 17 Sec. 13. NEW SECTION. 514J.13 STANDARD OF REVIEW.
11 18 The standard of review used by an independent review entity
11 19 shall be whether the health care service or treatment denied
11 20 by the carrier or organized delivery system was medically
11 21 necessary. The independent review entity shall take into
11 22 consideration factors identified in the review record that
11 23 impact the delivery of or describe the standard of care for
11 24 the health care service or treatment under review. The health
11 25 care service or treatment recommended by the enrollee's
11 26 treating health care provider shall be upheld upon review so
11 27 long as it is found to be medically necessary.
11 28 Sec. 14. NEW SECTION. 514J.14 EFFECT OF EXTERNAL REVIEW
11 29 DECISION.
11 30 The review decision by the independent review entity
11 31 conducting the review is binding upon the carrier or organized
11 32 delivery system. The enrollee, or the enrollee's treating
11 33 health care provider acting on behalf of the enrollee, may
11 34 appeal the review decision by the independent review entity
11 35 conducting the review by filing a petition for judicial review
12 1 either in Polk county district court or in the district court
12 2 in the county in which the enrollee resides.
12 3 Sec. 15. NEW SECTION. 514J.15 ADEQUACY OF PROVIDER
12 4 NETWORK.
12 5 A carrier or organized delivery system shall have a
12 6 sufficient number, distribution, and variety of qualified
12 7 participating health care providers to ensure that all covered
12 8 health care services, including specialty services, will be
12 9 available and accessible in a timely manner to all enrollees.
12 10 Whenever possible, primary health care services and specialty
12 11 health care services ordinarily provided on an outpatient or
12 12 clinic basis shall be available within thirty minutes' travel
12 13 time for enrollees and, with the exception of secondary or
12 14 tertiary levels of inpatient hospital services, inpatient
12 15 hospital services shall be available within sixty minutes'
12 16 travel time for the enrollee.
12 17 Sec. 16. NEW SECTION. 514J.16 EMERGENCY SERVICES.
12 18 1. A carrier or organized delivery system which provides
12 19 coverage for emergency services is responsible for charges for
12 20 emergency services provided to an enrollee, including services
12 21 furnished outside any participating provider network or
12 22 preferred provider network. Coverage for emergency services
12 23 is subject to the terms and conditions of the health care
12 24 services benefit plan or contract, not inconsistent with this
12 25 section. The enrollee shall not be liable for amounts that
12 26 exceed the amounts of liability that would be incurred if the
12 27 health care services were provided by a participating health
12 28 care provider, and the carrier or organized delivery system
12 29 shall pay an amount that is not less than the amount paid to a
12 30 participating health care provider for the same health care
12 31 services.
12 32 2. Prior authorization for emergency services shall not be
12 33 required. All health care services necessary to evaluate and
12 34 stabilize the enrollee shall be considered covered emergency
12 35 services.
13 1 3. A carrier or organized delivery system is responsible
13 2 for charges for maintenance health care services or
13 3 poststabilization health care services provided by
13 4 nonparticipating health care providers if transfer of the care
13 5 to a participating health care provider was unreasonable or
13 6 impracticable, consistent with guidelines developed by the
13 7 commissioner.
13 8 Sec. 17. NEW SECTION. 514J.17 TREATMENT OPTIONS –
13 9 PROHIBITION AGAINST RETALIATION.
13 10 1. A carrier or organized delivery system shall not
13 11 prohibit a participating health care provider from doing any
13 12 of the following:
13 13 a. Discussing treatment options with an enrollee,
13 14 notwithstanding the carrier or organized delivery system's
13 15 position on such treatment option.
13 16 b. Advocating on behalf of an enrollee within a review or
13 17 grievance process, established by the carrier or organized
13 18 delivery system or established by a person contracting with
13 19 the carrier or organized delivery system.
13 20 2. A carrier or organized delivery system shall not
13 21 retaliate or discriminate against an enrollee or a
13 22 participating health care provider for doing any of the
13 23 following:
13 24 a. The enrollee's or health care provider's use of, or
13 25 participation in, a utilization review process, grievance
13 26 process, or appeal process of the carrier or organized
13 27 delivery system.
13 28 b. Good faith disclosure of information relating to, or
13 29 participation in an investigation of, the carrier or organized
13 30 delivery system by a regulatory agency of the state or federal
13 31 government.
13 32 Sec. 18. NEW SECTION. 514J.18 PROHIBITION ON ARBITRARY
13 33 LIMITATIONS BASED ON MEDICAL NECESSITY.
13 34 A carrier or organized delivery system shall not
13 35 arbitrarily limit, alter, or otherwise interfere with the
14 1 determination or recommendations of the enrollee's treating
14 2 health care provider regarding the manner or setting in which
14 3 particular health care services are delivered, if the health
14 4 care services are medically necessary for treatment.
14 5 Sec. 19. NEW SECTION. 514J.19 DISCLOSURE OF INFORMATION
14 6 TO ENROLLEES.
14 7 1. The commissioner or the director of public health, as
14 8 appropriate, shall adopt rules regarding disclosure of
14 9 information by carriers and organized delivery systems to
14 10 enrollees or prospective enrollees. The rules shall specify
14 11 that the information shall be understandable, user-friendly,
14 12 and readily accessible.
14 13 2. A carrier or organized delivery system shall make
14 14 available to the commissioner or director of public health, as
14 15 applicable, information regarding overall loss-ratios and
14 16 medical loss-ratios, or the percentage of total premium
14 17 revenue spent on medical care compared to administrative costs
14 18 and plan marketing. The commissioner or director shall
14 19 release the information to the public upon request.
14 20 3. Information required to be disclosed under this section
14 21 and rules of the commissioner or director of public health
14 22 shall be provided in accordance with available uniform
14 23 national reporting standards.
14 24 Sec. 20. NEW SECTION. 514J.20 CONFIDENTIALITY.
14 25 A carrier or organized delivery system shall maintain
14 26 medical records or other health information regarding
14 27 enrollees in a manner that safeguards the privacy of any
14 28 individual identified in such information.
14 29 Sec. 21. NEW SECTION. 514J.21 PROHIBITION AGAINST
14 30 TRANSFER OF INDEMNIFICATION.
14 31 A contract or agreement between a carrier or organized
14 32 delivery system and a participating health care provider shall
14 33 not contain any provision purporting to transfer to the health
14 34 care provider, by indemnification or otherwise, any liability
14 35 relating to activities, actions, or omissions of the carrier
15 1 or organized delivery system which are not the activities,
15 2 actions, or omissions of the participating health care
15 3 provider.
15 4 Sec. 22. NEW SECTION. 514J.22 PROHIBITION AGAINST
15 5 UNREASONABLE DELAYS IN PAYMENTS TO ENROLLEES OR HEALTH CARE
15 6 PROVIDERS.
15 7 1. Carriers and organized delivery systems shall reimburse
15 8 claimants for all clean health insurance claims for covered
15 9 health care services filed electronically within fourteen days
15 10 of claim submission, and within thirty days when the claim is
15 11 submitted on paper.
15 12 2. A carrier or organized delivery system that does not
15 13 comply with subsection 1 shall pay interest to the claimant,
15 14 accruing from the date after payment was due, on that amount
15 15 of the claim that remains unpaid. The amount of interest
15 16 shall be established by rule of the commissioner for carriers
15 17 or the director of public health organized delivery systems,
15 18 as appropriate.
15 19 3. If there is a good faith dispute regarding the
15 20 legitimacy of a claim or the appropriate amount of
15 21 reimbursement, notice that a dispute exists shall be furnished
15 22 by the carrier or organized delivery system to the claimant,
15 23 upon receipt of the claim.
15 24 Sec. 23. NEW SECTION. 514J.23 RULEMAKING BY THE
15 25 COMMISSION – DIRECTOR OF PUBLIC HEALTH REPORT TO THE GENERAL
15 26 ASSEMBLY.
15 27 The commissioner, or the director of public health, as
15 28 appropriate, shall adopt rules as necessary to administer this
15 29 chapter. Nothing in this chapter shall preclude the
15 30 commissioner or the director of public health, as appropriate,
15 31 from adopting rules consistent with the commissioner's or
15 32 director's regulatory authority to address matters not
15 33 otherwise addressed in this chapter. The commissioner or
15 34 director, in consultation with representatives of carriers,
15 35 organized delivery systems, health care providers, and
16 1 enrollees, shall monitor implementation of the provisions of
16 2 this chapter and the effectiveness of those provisions and
16 3 shall prepare a report to the general assembly recommending
16 4 consideration of new provisions or changes to existing
16 5 provisions to assure high-quality, accessible, and fair
16 6 processes and procedures in the receipt of covered benefits.
16 7 The report shall be submitted to the general assembly by
16 8 January 1, 2000.
16 9 EXPLANATION
16 10 This bill establishes provisions for the protection of
16 11 enrollees receiving health care services coverage by a carrier
16 12 or an organized delivery system, and participating providers.
16 13 The bill provides definitions and applies to all carriers
16 14 which includes any entity performing utilization review which
16 15 is subject to the insurance laws and regulations of the state
16 16 or subject to the jurisdiction of the commissioner of
16 17 insurance and also applies to organized delivery systems
16 18 (ODSs), which are under the jurisdiction of the director of
16 19 public health.
16 20 The bill includes utilization review requirements by
16 21 requiring a carrier or ODS to meet the requirements
16 22 established for accreditation by the utilization review
16 23 accreditation commission (URAC), the national commission on
16 24 quality assurance (NCQA), or another national accreditation
16 25 entity recognized and approved by the commissioner. The bill
16 26 also specifies that utilization review is to be carried out
16 27 only by qualified personnel and is to be conducted under the
16 28 direction of a physician. The bill provides for
16 29 confidentiality of information regarding the enrollee and
16 30 excludes from application of the requirements any denials of
16 31 coverage of preauthorized treatment pursuant to utilization
16 32 review conducted solely under contract with the federal
16 33 government.
16 34 The bill provides for an external review process for the
16 35 appeal of a denial of coverage based upon medical necessity.
17 1 The bill includes provisions relating to eligibility of an
17 2 enrollee for external review, designates independent review
17 3 entities eligible to conduct external review, outlines the
17 4 external review process, provides for expedited review when
17 5 delay would pose an imminent or serious threat to the life or
17 6 health of the enrollee, provides that the costs of the
17 7 external review are to be paid by the carrier or ODS, requires
17 8 annual reporting by carriers and ODSs relating to external
17 9 reviews, provides certain immunity for an independent review
17 10 entity carrying out the external review, provides that the
17 11 standard of review is whether the health care service denied
17 12 by the carrier or ODS was medically necessary, and provides
17 13 that the decision following the external review is binding on
17 14 the carrier or ODS, but that the enrollee may seek judicial
17 15 review of the decision.
17 16 The bill includes provisions relating to the adequacy of a
17 17 carrier or ODS provider network. The bill requires a carrier
17 18 or ODS to have a sufficient number, distribution, and variety
17 19 of qualified participating health care providers to ensure
17 20 that all covered health care services, including specialty
17 21 services, will be available and accessible in a timely manner
17 22 to all enrollees; and that travel time for enrollees to obtain
17 23 primary care and specialty care services on an outpatient
17 24 basis is to be 30 minutes and that, with the exception of
17 25 secondary or tertiary level of inpatient hospital service,
17 26 inpatient hospital services are to be accessible within 60
17 27 minutes' travel time.
17 28 The bill requires that a carrier or ODS which provides
17 29 coverage for emergency services is responsible for the charges
17 30 for emergency services provided to an enrollee, consistent
17 31 with the plan or contract if not inconsistent with the
17 32 requirements of the bill. The bill prohibits the requirement
17 33 of prior authorization for emergency services, including
17 34 services necessary to evaluate and stabilize the patient and
17 35 for charges for maintenance care or poststabilization care
18 1 provided by nonparticipating providers if it is unreasonable
18 2 or impracticable for participating providers to provide the
18 3 services.
18 4 The bill prohibits a carrier or ODS from prohibiting
18 5 participating health care providers from discussing treatment
18 6 options with an enrollee, notwithstanding the position of the
18 7 carrier or ODS, or from advocating on behalf of an enrollee
18 8 within a review or grievance process. The bill also prohibits
18 9 a carrier or ODS from retaliating or discriminating against an
18 10 enrollee or a participating provider for their participation
18 11 in a utilization review, grievance, or appeal process, or for
18 12 good faith disclosure of information relating to or
18 13 participation in an investigation of the carrier or ODS by a
18 14 regulatory agency.
18 15 The bill prohibits a carrier or ODS from arbitrarily
18 16 limiting, altering, or otherwise interfering with the
18 17 determinations or recommendations of the treating health care
18 18 provider relating to a particular service if the service is
18 19 medically necessary.
18 20 The bill requires a carrier or ODS to disclose certain
18 21 information, pursuant to rules adopted by the commissioner of
18 22 insurance or the director of public health, to enrollees or
18 23 prospective enrollees, including overall loss ratios and
18 24 medical loss ratios, or percentages of total premium revenue
18 25 spent on medical care compared with administrative costs and
18 26 plan marketing.
18 27 The bill requires carriers and ODSs to maintain medical
18 28 record or other health information regarding enrollees in a
18 29 manner that safeguards the privacy of any individual
18 30 identified in enrollee information.
18 31 The bill prohibits a carrier or ODS from including in a
18 32 contract with a provider any provision to transfer to the
18 33 health care provider indemnification or otherwise any
18 34 liability relating to activities, actions, or omissions of the
18 35 carrier or ODS which are not activities, actions, or omissions
19 1 of the provider.
19 2 The bill prohibits unreasonable delays in payments to
19 3 enrollees or health care providers.
19 4 The bill directs the commissioner of insurance and the
19 5 director of public health, as appropriate, to adopt rules and
19 6 to monitor the provisions of the bill and submit a report to
19 7 the general assembly by January 1, 2000, recommending
19 8 consideration of new or changed provisions to assure high-
19 9 quality, accessible, and fair processes and procedures in
19 10 receipt of covered benefits.
19 11 LSB 1415YC 78
19 12 pf/cf/24
Text: HSB00243 Text: HSB00245 Text: HSB00200 - HSB00299 Text: HSB Index Bills and Amendments: General Index Bill History: General Index
© 1999 Cornell College and League of Women Voters of Iowa
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