House
Study
Bill
200
-
Introduced
SENATE/HOUSE
FILE
_____
BY
(PROPOSED
DEPARTMENT
OF
COMMERCE/INSURANCE
DIVISION
BILL)
A
BILL
FOR
An
Act
creating
new
procedures
for
external
review
of
health
1
care
coverage
decisions
by
health
carriers
and
including
2
transition
and
applicability
provisions.
3
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
4
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Section
1.
NEW
SECTION
.
514J.101
Purpose
——
applicability.
1
The
purpose
of
this
chapter
is
to
provide
uniform
standards
2
for
the
establishment
and
maintenance
of
external
review
3
procedures
to
assure
that
covered
persons
have
the
opportunity
4
for
an
independent
review
of
an
adverse
determination
or
final
5
adverse
determination
made
by
a
health
carrier
as
required
6
by
the
federal
Patient
Protection
and
Affordable
Care
Act,
7
Pub.
L.
No.
111-148,
as
amended
by
the
federal
Health
Care
and
8
Education
Reconciliation
Act
of
2010,
Pub.
L.
No.
111-152,
9
which
amends
the
Public
Health
Service
Act
and
adopts,
in
part,
10
new
42
U.S.C.
§
300gg-19,
and
to
address
issues
which
are
11
unique
to
the
external
review
process
in
this
state.
12
Sec.
2.
NEW
SECTION
.
514J.102
Definitions.
13
As
used
in
this
chapter,
unless
the
context
otherwise
14
requires:
15
1.
“Adverse
determination”
means
a
determination
by
a
health
16
carrier
that
an
admission,
availability
of
care,
continued
17
stay,
or
other
health
care
service
that
is
a
covered
benefit
18
has
been
reviewed
and,
based
upon
the
information
provided,
19
does
not
meet
the
health
carrier’s
requirements
for
medical
20
necessity,
appropriateness,
health
care
setting,
level
of
care,
21
or
effectiveness,
and
the
requested
service
or
payment
for
the
22
service
is
therefore
denied,
reduced,
or
terminated.
“Adverse
23
determination”
does
not
include
a
denial
of
coverage
for
a
24
service
or
treatment
specifically
listed
in
plan
or
evidence
25
of
coverage
documents
as
excluded
from
coverage,
or
a
denial
26
of
coverage
for
a
service
or
treatment
that
has
already
been
27
received
and
for
which
the
covered
person
has
no
financial
28
liability.
29
2.
“Authorized
representative”
means
any
of
the
following:
30
a.
A
person
to
whom
a
covered
person
has
given
express
31
written
consent
to
represent
the
covered
person
in
an
external
32
review.
33
b.
A
person
authorized
by
law
to
provide
substituted
consent
34
for
a
covered
person.
35
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c.
A
family
member
of
the
covered
person
when
the
covered
1
person
is
unable
to
provide
consent.
2
d.
The
covered
person’s
treating
health
care
professional
3
when
the
covered
person
is
unable
to
provide
consent.
4
3.
“Best
evidence”
means
evidence
based
on
randomized
5
clinical
trials.
If
randomized
clinical
trials
are
not
6
available,
“best
evidence”
means
evidence
based
on
cohort
7
studies
or
case-control
studies.
If
randomized
clinical
8
trials,
cohort
studies,
or
case-control
studies
are
not
9
available,
“best
evidence”
means
evidence
based
on
case-series
10
studies.
If
none
of
these
are
available,
“best
evidence”
means
11
evidence
based
on
expert
opinion.
12
4.
“Case-control
study”
means
a
retrospective
evaluation
13
of
two
groups
of
patients
with
different
outcomes
to
determine
14
which
specific
interventions
the
patients
received.
15
5.
“Case-series
study”
means
an
evaluation
of
a
series
16
of
patients
with
a
particular
outcome,
without
the
use
of
a
17
control
group.
18
6.
“Certification”
means
a
determination
by
a
health
carrier
19
that
an
admission,
availability
of
care,
continued
stay,
or
20
other
health
care
service
has
been
reviewed
and,
based
on
21
the
information
provided,
satisfies
the
health
carrier’s
22
requirements
for
medical
necessity,
appropriateness,
health
23
care
setting,
level
of
care,
and
effectiveness.
24
7.
“Clinical
review
criteria”
means
the
written
screening
25
procedures,
decision
abstracts,
clinical
protocols,
and
26
practice
guidelines
used
by
a
health
carrier
to
determine
the
27
necessity
and
appropriateness
of
health
care
services.
28
8.
“Cohort
study”
means
a
prospective
evaluation
of
two
29
groups
of
patients
with
only
one
group
of
patients
receiving
a
30
specific
intervention.
31
9.
“Commissioner”
means
the
commissioner
of
insurance.
32
10.
“Covered
benefits”
or
“benefits”
means
those
health
care
33
services
to
which
a
covered
person
is
entitled
under
the
terms
34
of
a
health
benefit
plan.
35
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_____
11.
“Covered
person”
means
a
policyholder,
subscriber,
1
enrollee,
or
other
individual
participating
in
a
health
benefit
2
plan.
3
12.
“Disclose”
means
to
release,
transfer,
or
otherwise
4
divulge
protected
health
information
to
any
person
other
than
5
the
individual
who
is
the
subject
of
the
protected
health
6
information.
7
13.
“Emergency
medical
condition”
means
the
sudden
and,
at
8
the
time,
unexpected
onset
of
a
health
condition
or
illness
9
that
requires
immediate
medical
attention,
where
failure
to
10
provide
medical
attention
would
result
in
a
serious
impairment
11
to
bodily
functions,
serious
dysfunction
of
a
bodily
organ
or
12
part,
or
would
place
the
person’s
health
in
serious
jeopardy.
13
14.
“Emergency
services”
means
health
care
items
and
14
services
furnished
or
required
to
evaluate
and
treat
an
15
emergency
medical
condition.
16
15.
“Evidence-based
standard”
means
the
conscientious,
17
explicit,
and
judicious
use
of
the
current
best
evidence
based
18
on
the
overall
systematic
review
of
the
research
in
making
19
decisions
about
the
care
of
individual
patients.
20
16.
“Expert
opinion”
means
a
belief
or
an
interpretation
21
by
specialists
with
experience
in
a
specific
area
about
22
the
scientific
evidence
pertaining
to
a
particular
service,
23
intervention,
or
therapy.
24
17.
“Facility”
means
an
institution
providing
health
25
care
services
or
a
health
care
setting,
including
but
not
26
limited
to
hospitals
and
other
licensed
inpatient
centers,
27
ambulatory
surgical
or
treatment
centers,
skilled
nursing
28
centers,
residential
treatment
centers,
diagnostic,
laboratory
29
and
imaging
centers,
and
rehabilitation
and
other
therapeutic
30
health
settings.
31
18.
“Final
adverse
determination”
means
an
adverse
32
determination
involving
a
covered
benefit
that
has
been
upheld
33
by
a
health
carrier
at
the
completion
of
the
health
carrier’s
34
internal
grievance
process.
35
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_____
19.
“Health
benefit
plan”
means
a
policy,
contract,
1
certificate,
or
agreement
offered
or
issued
by
a
health
carrier
2
to
provide,
deliver,
arrange
for,
pay
for,
or
reimburse
any
of
3
the
costs
of
health
care
services.
4
20.
“Health
care
professional”
means
a
physician
or
other
5
health
care
practitioner
licensed,
accredited,
registered,
or
6
certified
to
perform
specified
health
care
services
consistent
7
with
state
law.
8
21.
“Health
care
provider”
or
“provider”
means
a
health
care
9
professional
or
a
facility.
10
22.
“Health
care
services”
means
services
for
the
diagnosis,
11
prevention,
treatment,
cure,
or
relief
of
a
health
condition,
12
illness,
injury,
or
disease.
13
23.
“Health
carrier”
means
an
entity
subject
to
the
14
insurance
laws
and
regulations
of
this
state,
or
subject
15
to
the
jurisdiction
of
the
commissioner,
including
an
16
insurance
company
offering
sickness
and
accident
plans,
a
17
health
maintenance
organization,
a
nonprofit
health
service
18
corporation,
a
plan
established
pursuant
to
chapter
509A
19
for
public
employees,
or
any
other
entity
providing
a
plan
20
of
health
insurance,
health
care
benefits,
or
health
care
21
services.
“Health
carrier”
includes,
for
purposes
of
this
22
chapter,
an
organized
delivery
system.
23
24.
“Health
information”
means
information
or
data,
whether
24
oral
or
recorded
in
any
form
or
medium,
and
personal
facts
or
25
information
about
events
or
relationships
that
relates
to
any
26
of
the
following:
27
a.
The
past,
present,
or
future
physical,
mental,
or
28
behavioral
health
or
condition
of
a
covered
person
or
a
member
29
of
the
covered
person’s
family.
30
b.
The
provision
of
health
care
services
to
a
covered
31
person.
32
c.
Payment
to
a
health
care
provider
for
the
provision
of
33
health
care
services
to
a
covered
person.
34
25.
“Independent
review
organization”
means
an
entity
that
35
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_____
H.F.
_____
conducts
independent
external
reviews
of
adverse
determinations
1
and
final
adverse
determinations.
2
26.
“Medical
or
scientific
evidence”
means
evidence
found
in
3
any
of
the
following
sources:
4
a.
Peer-reviewed
scientific
studies
published
in
or
accepted
5
for
publication
by
medical
journals
that
meet
nationally
6
recognized
requirements
for
scientific
manuscripts
and
that
7
submit
most
of
their
published
articles
for
review
by
experts
8
who
are
not
part
of
the
editorial
staff.
9
b.
Peer-reviewed
medical
literature,
including
literature
10
relating
to
therapies
reviewed
and
approved
by
a
qualified
11
institutional
review
board,
biomedical
compendia,
and
other
12
medical
literature
that
meet
the
criteria
of
the
national
13
institutes
of
health’s
national
library
of
medicine
for
14
indexing
in
index
medicus
or
medline,
or
of
elsevier
science
15
ltd.
for
indexing
in
excerpta
medicus
or
embase.
16
c.
Medical
journals
recognized
by
the
United
States
17
secretary
of
health
and
human
services
under
section
1861(t)(2)
18
of
the
federal
Social
Security
Act.
19
d.
The
following
standard
reference
compendia:
20
(1)
American
hospital
formulary
service
drug
information.
21
(2)
Drug
facts
and
comparisons.
22
(3)
American
dental
association
accepted
dental
23
therapeutics.
24
(4)
United
States
pharmacopoeia
drug
information.
25
e.
Findings,
studies,
or
research
conducted
by
or
under
26
the
auspices
of
federal
government
agencies
and
nationally
27
recognized
federal
research
institutes,
including
any
of
the
28
following:
29
(1)
Federal
agency
for
health
care
research
and
quality.
30
(2)
National
institutes
of
health.
31
(3)
National
cancer
institute.
32
(4)
National
academy
of
sciences.
33
(5)
Centers
for
Medicare
and
Medicaid
services.
34
(6)
Federal
food
and
drug
administration.
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(7)
Any
national
board
recognized
by
the
national
1
institutes
of
health
for
the
purpose
of
evaluating
the
medical
2
value
of
health
care
services.
3
f.
Any
other
medical
or
scientific
evidence
that
is
4
comparable
to
the
sources
listed
in
paragraphs
“a”
through
“e”
.
5
27.
“NAIC”
means
the
national
association
of
insurance
6
commissioners.
7
28.
“Organized
delivery
system”
means
an
entity
system
8
authorized
under
1993
Iowa
Acts,
ch.
158,
and
licensed
by
the
9
director
of
public
health,
and
performing
utilization
review.
10
29.
“Person”
means
an
individual,
a
corporation,
a
11
partnership,
an
association,
a
joint
venture,
a
joint
stock
12
company,
a
trust,
an
unincorporated
organization,
any
similar
13
entity,
or
any
combination
of
the
foregoing.
14
30.
“Protected
health
information”
means
health
information
15
that
meets
either
of
the
following
descriptions:
16
a.
Health
information
that
identifies
a
covered
person
who
17
is
the
subject
of
the
information.
18
b.
Health
information
with
respect
to
which
there
is
a
19
reasonable
basis
to
believe
that
the
information
could
be
used
20
to
identify
a
covered
person.
21
31.
“Randomized
clinical
trial”
means
a
controlled,
22
prospective
study
of
patients
that
have
been
randomized
into
an
23
experimental
group
and
a
control
group
at
the
beginning
of
the
24
study
with
only
the
experimental
group
of
patients
receiving
a
25
specific
intervention,
which
includes
study
of
the
groups
for
26
variables
and
anticipated
outcomes
over
time.
27
Sec.
3.
NEW
SECTION
.
514J.103
Applicability
and
scope.
28
1.
Except
as
provided
in
subsection
2,
this
chapter
shall
29
apply
to
all
health
carriers.
30
2.
This
chapter
shall
not
apply
to
any
of
the
following:
31
a.
A
policy
or
certificate
that
provides
coverage
only
for
a
32
specified
disease,
specified
accident
or
accident-only,
credit,
33
disability
income,
hospital
indemnity,
long-term
care,
dental
34
care,
vision
care,
or
any
other
limited
supplemental
benefit.
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b.
A
Medicare
supplement
policy
of
insurance,
as
defined
by
1
the
commissioner
by
rule.
2
c.
Coverage
under
a
plan
through
Medicare,
Medicaid,
or
the
3
federal
employees
health
benefits
program,
any
coverage
issued
4
under
10
U.S.C.
ch.
55,
and
any
coverage
issued
as
supplemental
5
to
that
coverage.
6
d.
Any
coverage
issued
as
supplemental
to
liability
7
insurance.
8
e.
Workers’
compensation
or
similar
insurance.
9
f.
Automobile
medical-payment
insurance
or
any
insurance
10
under
which
benefits
are
payable
with
or
without
regard
to
11
fault,
whether
written
on
a
group
blanket
or
individual
basis.
12
Sec.
4.
NEW
SECTION
.
514J.104
Notice
of
right
to
external
13
review.
14
1.
A
health
carrier
shall
notify
a
covered
person
or
the
15
covered
person’s
authorized
representative,
if
known,
in
16
writing
of
the
covered
person’s
right
to
request
an
external
17
review
and
include
the
appropriate
statements
and
information
18
set
forth
in
this
chapter
at
the
time
the
health
carrier
sends
19
written
notice
of
a
final
adverse
determination.
20
2.
a.
The
notice
shall
include
the
following,
or
21
substantially
equivalent,
language:
22
We
have
denied
your
request
for
the
provision
of
or
payment
23
for
a
health
care
service
or
course
of
treatment.
You
may
24
have
the
right
to
have
our
decision
reviewed
by
health
care
25
professionals
who
have
no
association
with
us
if
our
decision
26
involved
making
a
judgment
as
to
the
medical
necessity,
27
appropriateness,
health
care
setting,
level
of
care,
or
28
effectiveness
of
the
health
care
service
or
treatment
you
29
requested
by
submitting
a
request
for
external
review
to
the
30
commissioner
of
insurance.
31
b.
The
notice
shall
include
the
current
address
and
contact
32
information
for
the
commissioner
as
specified
in
administrative
33
rule.
34
3.
The
health
carrier
shall
include
in
the
notice
a
35
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statement
informing
the
covered
person
or
the
covered
person’s
1
authorized
representative,
if
known,
of
the
following:
2
a.
If
the
covered
person
has
a
medical
condition
pursuant
3
to
which
the
time
frame
for
completion
of
a
standard
external
4
review
would
seriously
jeopardize
the
life
or
health
of
the
5
covered
person
or
would
jeopardize
the
covered
person’s
ability
6
to
regain
maximum
function,
the
covered
person
or
the
covered
7
person’s
authorized
representative
may
file
a
request
for
an
8
expedited
external
review.
9
b.
If
the
final
adverse
determination
concerns
an
admission,
10
availability
of
care,
continued
stay,
or
health
care
service
11
for
which
the
covered
person
received
emergency
services,
but
12
has
not
been
discharged
from
a
facility,
the
covered
person
or
13
the
covered
person’s
authorized
representative
may
request
an
14
expedited
external
review.
15
c.
If
the
final
adverse
determination
concerns
a
denial
16
of
coverage
based
on
a
determination
that
the
recommended
or
17
requested
health
care
service
or
treatment
is
experimental
18
or
investigational
as
provided
in
section
514J.109,
and
the
19
covered
person’s
treating
health
care
professional
certifies
20
in
writing
that
the
recommended
or
requested
health
care
21
service
or
treatment
that
is
the
subject
of
the
recommendation
22
or
request
would
be
significantly
less
effective
if
not
23
promptly
initiated,
the
covered
person
or
the
covered
person’s
24
authorized
representative
may
request
an
expedited
external
25
review.
26
4.
The
health
carrier
shall
include
with
the
notice
a
copy
27
of
the
descriptions
of
both
the
standard
and
expedited
external
28
review
procedures
the
health
carrier
is
required
to
provide
29
pursuant
to
section
514J.116,
highlighting
the
provisions
in
30
the
external
review
procedures
that
give
the
covered
person
or
31
the
covered
person’s
authorized
representative
the
opportunity
32
to
submit
additional
information
and
including
any
forms
used
33
to
process
an
external
review.
34
5.
The
health
carrier
shall
also
include
with
the
notice
35
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an
authorization
form,
or
other
document
approved
by
the
1
commissioner
that
complies
with
the
requirements
of
45
C.F.R.
2
§
164.508
and
with
Tit.
I
of
the
federal
Genetic
Information
3
Nondiscrimination
Act
of
2008,
Pub.
L.
No.
110-233,
122
Stat.
4
881,
by
which
the
covered
person
or
the
covered
person’s
5
authorized
representative
authorizes
the
health
carrier
and
6
the
covered
person’s
treating
health
care
provider
to
disclose
7
protected
health
information,
including
medical
records,
8
concerning
the
covered
person
that
is
pertinent
to
the
external
9
review.
10
Sec.
5.
NEW
SECTION
.
514J.105
Request
for
external
review.
11
A
covered
person
or
the
covered
person’s
authorized
12
representative
may
make
a
request
for
an
external
review
of
13
a
final
adverse
determination.
Except
for
a
request
for
an
14
expedited
external
review,
all
requests
for
external
review
15
shall
be
made
in
writing
to
the
commissioner.
The
commissioner
16
may
prescribe
by
rule
the
form
and
content
of
external
review
17
requests.
18
Sec.
6.
NEW
SECTION
.
514J.106
Exhaustion
of
internal
19
grievance
process
——
exceptions
——
expedited
external
review
20
request.
21
1.
Except
as
otherwise
provided
in
this
section,
a
request
22
for
an
external
review
shall
not
be
made
until
the
covered
23
person
or
the
covered
person’s
authorized
representative
has
24
exhausted
the
health
carrier’s
internal
grievance
process
and
25
received
a
final
adverse
determination.
26
2.
A
covered
person
or
the
covered
person’s
authorized
27
representative
shall
be
considered
to
have
exhausted
the
health
28
carrier’s
internal
grievance
process
if
the
covered
person
or
29
the
covered
person’s
authorized
representative
has
filed
a
30
grievance
involving
an
adverse
determination
and,
except
to
the
31
extent
the
covered
person
or
the
covered
person’s
authorized
32
representative
requested
or
agreed
to
a
delay,
has
not
received
33
a
written
decision
on
the
grievance
from
the
health
carrier
34
within
thirty
days
following
the
date
the
covered
person
or
the
35
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covered
person’s
authorized
representative
filed
the
grievance
1
with
the
health
carrier.
2
3.
A
covered
person
or
the
covered
person’s
authorized
3
representative
may
file
a
request
for
an
expedited
external
4
review
of
an
adverse
determination
without
exhausting
the
5
health
carrier’s
internal
grievance
process
under
either
of
the
6
following
circumstances:
7
a.
The
covered
person
has
a
medical
condition
pursuant
8
to
which
the
time
frame
for
completion
of
an
internal
review
9
of
the
grievance
involving
an
adverse
determination
would
10
seriously
jeopardize
the
life
or
health
of
the
covered
person
11
or
would
jeopardize
the
covered
person’s
ability
to
regain
12
maximum
function
as
provided
in
section
514J.108.
13
b.
The
adverse
determination
involves
a
denial
of
14
coverage
based
on
a
determination
that
the
recommended
or
15
requested
health
care
service
or
treatment
is
experimental
or
16
investigational
and
the
covered
person’s
treating
physician
17
certifies
in
writing
that
the
recommended
or
requested
health
18
care
service
or
treatment
that
is
the
subject
of
the
adverse
19
determination
would
be
significantly
less
effective
if
not
20
promptly
initiated
as
provided
in
section
514J.109.
21
4.
A
request
for
an
external
review
of
an
adverse
22
determination
may
be
made
before
the
covered
person
or
the
23
covered
person’s
authorized
representative
has
exhausted
the
24
health
carrier’s
internal
grievance
procedures
whenever
the
25
health
carrier
agrees
to
waive
the
exhaustion
requirement.
26
If
the
requirement
to
exhaust
the
health
carrier’s
internal
27
grievance
procedures
is
waived,
the
covered
person
or
the
28
covered
person’s
authorized
representative
may
file
a
request
29
with
the
commissioner
in
writing
for
a
standard
external
30
review.
31
Sec.
7.
NEW
SECTION
.
514J.107
External
review
——
standard.
32
1.
A
covered
person
or
the
covered
person’s
authorized
33
representative
may
file
a
written
request
for
an
external
34
review
with
the
commissioner
within
four
months
after
any
of
35
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the
following
events:
1
a.
The
date
of
receipt
of
a
final
adverse
determination.
2
b.
The
failure
of
a
health
carrier
to
issue
a
written
3
decision
within
thirty
days
following
the
date
the
covered
4
person
or
the
covered
person’s
authorized
representative
filed
5
a
grievance
involving
an
adverse
determination
as
provided
in
6
section
514J.106,
subsection
2.
7
c.
The
agreement
of
the
health
carrier
to
waive
the
8
requirement
that
the
covered
person
or
the
covered
person’s
9
authorized
representative
exhaust
the
health
carrier’s
internal
10
grievance
procedures
before
filing
a
request
for
external
11
review
of
an
adverse
determination
as
provided
in
section
12
514J.106,
subsection
4.
13
2.
Within
one
business
day
after
the
date
of
receipt
of
a
14
request
for
external
review,
the
commissioner
shall
send
a
copy
15
of
the
request
to
the
health
carrier.
16
3.
Within
five
business
days
following
the
date
of
receipt
17
of
the
external
review
request
from
the
commissioner,
the
18
health
carrier
shall
complete
a
preliminary
review
of
the
19
request
to
determine
whether:
20
a.
The
individual
is
or
was
a
covered
person
under
the
21
health
benefit
plan
at
the
time
the
health
care
service
was
22
recommended
or
requested.
23
b.
The
health
care
service
that
is
the
subject
of
the
24
adverse
determination
or
of
the
final
adverse
determination,
25
is
a
covered
service
under
the
covered
person’s
health
benefit
26
plan,
but
for
a
determination
by
the
health
carrier
that
the
27
health
care
service
is
not
covered
because
it
does
not
meet
28
the
health
carrier’s
requirements
for
medical
necessity,
29
appropriateness,
health
care
setting,
level
of
care,
or
30
effectiveness.
31
c.
The
covered
person
or
the
covered
person’s
authorized
32
representative
has
exhausted
the
health
carrier’s
internal
33
grievance
process,
unless
the
covered
person
or
the
covered
34
person’s
authorized
representative
is
not
required
to
exhaust
35
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the
health
carrier’s
internal
grievance
process
pursuant
to
1
section
514J.106
or
this
section.
2
d.
The
covered
person
or
the
covered
person’s
authorized
3
representative
has
provided
all
the
information
and
forms
4
required
to
process
an
external
review
request.
5
4.
Within
one
business
day
after
completion
of
a
preliminary
6
review
pursuant
to
subsection
3,
the
health
carrier
shall
7
notify
the
commissioner
and
the
covered
person
or
the
covered
8
person’s
authorized
representative
in
writing
whether
the
9
request
is
complete
and
whether
the
request
is
eligible
for
10
external
review.
11
a.
If
the
health
carrier
determines
that
the
request
is
not
12
complete,
the
health
carrier
shall
notify
the
covered
person
13
or
the
covered
person’s
authorized
representative
and
the
14
commissioner
in
writing
that
the
request
is
not
complete
and
15
what
information
or
materials
are
needed
to
make
the
request
16
complete.
17
b.
If
the
health
carrier
determines
that
the
request
is
18
not
eligible
for
external
review,
the
health
carrier
shall
19
issue
a
notice
of
initial
determination
in
writing
informing
20
the
covered
person
or
the
covered
person’s
authorized
21
representative
and
the
commissioner
of
that
determination
22
and
the
reasons
the
request
is
not
eligible
for
review.
The
23
health
carrier
shall
also
include
a
statement
in
the
notice
24
informing
the
covered
person
or
the
covered
person’s
authorized
25
representative
that
the
health
carrier’s
initial
determination
26
of
ineligibility
may
be
appealed
to
the
commissioner.
27
5.
The
commissioner
may
specify
by
rule
the
form
required
28
for
the
health
carrier’s
notice
of
initial
determination
and
29
any
supporting
information
to
be
included
in
the
notice.
30
6.
The
commissioner
may
determine
that
a
request
is
eligible
31
for
external
review,
notwithstanding
a
health
carrier’s
initial
32
determination
that
the
request
is
not
eligible,
and
refer
the
33
request
for
external
review.
In
making
this
determination,
the
34
commissioner’s
decision
shall
be
made
in
accordance
with
the
35
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terms
of
the
covered
person’s
health
benefit
plan
and
shall
be
1
subject
to
all
applicable
provisions
of
this
chapter.
2
7.
Within
one
business
day
after
receipt
of
notice
from
3
a
health
carrier
that
a
request
for
external
review
is
4
eligible
for
external
review
or
upon
a
determination
by
the
5
commissioner
that
a
request
is
eligible
for
external
review,
6
the
commissioner
shall
do
all
of
the
following:
7
a.
Assign
an
independent
review
organization
from
the
list
8
of
approved
independent
review
organizations
maintained
by
the
9
commissioner
and
notify
the
health
carrier
of
the
name
of
the
10
assigned
independent
review
organization.
The
assignment
of
11
an
independent
review
organization
shall
be
done
on
a
random
12
basis
among
those
approved
independent
review
organizations
13
qualified
to
conduct
the
particular
external
review
based
on
14
the
nature
of
the
health
care
service
that
is
the
subject
of
15
the
adverse
determination
or
final
adverse
determination
and
16
other
circumstances,
including
conflict
of
interest
concerns.
17
b.
Notify
the
covered
person
or
the
covered
person’s
18
authorized
representative
in
writing
that
the
request
is
19
eligible
and
has
been
accepted
for
external
review
including
20
the
name
of
the
assigned
independent
review
organization
and
21
that
the
covered
person
or
the
covered
person’s
authorized
22
representative
may
submit
in
writing
to
the
independent
review
23
organization
within
five
business
days
following
receipt
of
24
such
notice
from
the
commissioner,
additional
information
25
that
the
independent
review
organization
shall
consider
26
when
conducting
the
external
review.
The
independent
review
27
organization
may,
in
the
organization’s
discretion,
accept
and
28
consider
additional
information
submitted
by
the
covered
person
29
or
the
covered
person’s
authorized
representative
after
five
30
business
days.
31
8.
Within
five
business
days
after
receipt
of
notice
from
32
the
commissioner
pursuant
to
subsection
7,
the
health
carrier
33
shall
provide
to
the
independent
review
organization
the
34
documents
and
any
information
considered
in
making
the
adverse
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determination
or
final
adverse
determination.
Failure
by
the
1
health
carrier
to
provide
the
documents
and
information
within
2
the
time
specified
shall
not
delay
the
conduct
of
the
external
3
review.
4
9.
If
the
health
carrier
fails
to
provide
the
documents
5
and
information
within
the
time
specified,
the
independent
6
review
organization
may
terminate
the
external
review
and
7
make
a
decision
to
reverse
the
adverse
determination
or
final
8
adverse
determination.
Within
one
business
day
after
making
9
such
a
decision,
the
independent
review
organization
shall
10
notify
the
covered
person
or
the
covered
person’s
authorized
11
representative,
the
health
carrier,
and
the
commissioner
of
its
12
decision.
13
10.
The
independent
review
organization
shall
review
14
all
of
the
information
and
documents
received
pursuant
to
15
subsection
8
and
any
other
information
submitted
in
writing
16
to
the
independent
review
organization
by
the
covered
person
17
or
the
covered
person’s
authorized
representative
pursuant
to
18
subsection
7,
paragraph
“b”
.
Upon
receipt
of
any
information
19
submitted
by
the
covered
person
or
the
covered
person’s
20
authorized
representative,
the
independent
review
organization
21
shall,
within
one
business
day,
forward
the
information
to
the
22
health
carrier.
In
reaching
a
decision
the
independent
review
23
organization
is
not
bound
by
any
decisions
or
conclusions
24
reached
during
the
health
carrier’s
internal
grievance
process.
25
11.
Upon
receipt
of
information
forwarded
pursuant
to
26
subsection
10,
a
health
carrier
may
reconsider
its
adverse
27
determination
or
final
adverse
determination
that
is
the
28
subject
of
the
external
review.
29
a.
Reconsideration
by
the
health
carrier
of
its
30
determination
shall
not
delay
or
terminate
the
external
review.
31
The
external
review
shall
only
be
terminated
if
the
health
32
carrier
decides,
upon
completion
of
its
reconsideration,
to
33
reverse
its
determination
and
provide
coverage
or
payment
for
34
the
health
care
service
that
is
the
subject
of
the
adverse
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determination
or
final
adverse
determination.
1
b.
Within
one
business
day
after
making
a
decision
2
to
reverse
its
adverse
determination
or
final
adverse
3
determination,
the
health
carrier
shall
notify
the
covered
4
person
or
the
covered
person’s
authorized
representative,
5
the
independent
review
organization,
and
the
commissioner
in
6
writing
of
its
decision.
The
independent
review
organization
7
shall
terminate
the
external
review
upon
receipt
of
notice
8
of
the
health
carrier’s
decision
to
reverse
its
adverse
9
determination
or
final
adverse
determination.
10
12.
In
addition
to
the
documents
and
information
provided
to
11
the
independent
review
organization
pursuant
to
this
section,
12
the
independent
review
organization
shall,
to
the
extent
the
13
information
or
documents
are
available
and
the
independent
14
review
organization
considers
them
appropriate,
consider
the
15
following
in
reaching
a
decision:
16
a.
The
covered
person’s
pertinent
medical
records.
17
b.
The
treating
health
care
professional’s
recommendation.
18
c.
Consulting
reports
from
appropriate
health
care
19
professionals
and
other
documents
submitted
by
the
health
20
carrier,
covered
person,
or
the
covered
person’s
treating
21
physician
or
other
health
care
professional.
22
d.
The
terms
of
coverage
under
the
covered
person’s
health
23
benefit
plan
with
the
health
carrier,
to
ensure
that
the
24
independent
review
organization’s
decision
is
not
contrary
to
25
the
terms
of
coverage
under
the
covered
person’s
health
benefit
26
plan
with
the
health
carrier.
27
e.
The
most
appropriate
practice
guidelines,
which
shall
28
include
applicable
evidence-based
standards
and
may
include
any
29
other
practice
guidelines
developed
by
the
federal
government,
30
national
or
professional
medical
societies,
boards,
and
31
associations.
32
f.
Any
applicable
clinical
review
criteria
developed
and
33
used
by
the
health
carrier.
34
g.
The
opinion
of
the
independent
review
organization’s
35
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clinical
reviewer
after
considering
the
information
or
1
documents
described
in
paragraphs
“a”
through
“f”
to
the
extent
2
the
information
or
documents
are
available
and
the
clinical
3
reviewer
considers
them
relevant.
4
13.
a.
Within
forty-five
days
after
the
date
of
receipt
5
of
a
request
for
an
external
review,
the
independent
review
6
organization
shall
provide
written
notice
of
its
decision
to
7
uphold
or
reverse
the
adverse
determination
or
final
adverse
8
determination
of
the
health
carrier
to
the
covered
person
or
9
the
covered
person’s
authorized
representative,
the
health
10
carrier,
and
the
commissioner.
11
b.
The
independent
review
organization
shall
include
in
its
12
decision
all
of
the
following:
13
(1)
A
general
description
of
the
reason
for
the
request
for
14
external
review.
15
(2)
The
date
the
independent
review
organization
received
16
the
assignment
from
the
commissioner
to
conduct
the
external
17
review.
18
(3)
The
date
the
external
review
was
conducted.
19
(4)
The
date
of
the
decision.
20
(5)
The
principal
reason
or
reasons
for
its
decision,
21
including
what
applicable
evidence-based
standards,
if
any,
22
were
a
basis
for
its
decision.
23
(6)
The
rationale
for
its
decision.
24
(7)
References
to
evidence
or
documentation,
including
25
evidence-based
standards,
considered
in
reaching
its
decision.
26
14.
Upon
receipt
of
notice
of
a
decision
reversing
the
27
adverse
determination
or
final
adverse
determination
of
the
28
health
carrier,
the
health
carrier
shall
immediately
approve
29
the
coverage
that
was
the
subject
of
the
determination.
30
Sec.
8.
NEW
SECTION
.
514J.108
External
review
——
expedited.
31
1.
Notwithstanding
section
514J.107,
a
covered
person
or
32
the
covered
person’s
authorized
representative
may
make
an
33
oral
or
written
request
to
the
commissioner
for
an
expedited
34
external
review
at
the
time
the
covered
person
or
the
covered
35
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person’s
authorized
representative
receives
any
of
the
1
following:
2
a.
An
adverse
determination
that
involves
a
medical
3
condition
of
the
covered
person
for
which
the
time
frame
for
4
completion
of
an
internal
review
of
a
grievance
involving
an
5
adverse
determination
would
seriously
jeopardize
the
life
or
6
health
of
the
covered
person
or
would
jeopardize
the
covered
7
person’s
ability
to
regain
maximum
function.
8
b.
A
final
adverse
determination
that
involves
a
medical
9
condition
where
the
time
frame
for
completion
of
a
standard
10
external
review
would
seriously
jeopardize
the
life
or
health
11
of
the
covered
person
or
would
jeopardize
the
covered
person’s
12
ability
to
regain
maximum
function.
13
c.
A
final
adverse
determination
that
concerns
an
admission,
14
availability
of
care,
continued
stay,
or
health
care
service
15
for
which
the
covered
person
received
emergency
services,
and
16
has
not
been
discharged
from
a
facility.
17
2.
a.
Upon
receipt
of
a
request
for
an
expedited
external
18
review,
the
commissioner
shall
immediately
send
written
notice
19
of
the
request
to
the
health
carrier.
20
b.
Immediately
upon
receipt
of
notice
of
a
request
for
21
expedited
external
review,
the
health
carrier
shall
complete
22
a
preliminary
review
of
the
request
to
determine
whether
the
23
request
meets
the
eligibility
requirements
for
external
review
24
set
forth
in
section
514J.107,
subsection
3,
and
this
section.
25
c.
The
health
carrier
shall
then
immediately
issue
a
26
notice
of
initial
determination
informing
the
commissioner
27
and
the
covered
person
or
the
covered
person’s
authorized
28
representative
of
its
eligibility
determination
including
29
a
statement
informing
the
covered
person
or
the
covered
30
person’s
authorized
representative
of
the
right
to
appeal
that
31
determination
to
the
commissioner.
32
d.
The
commissioner
may
specify
by
rule
the
form
required
33
for
the
health
carrier’s
notice
of
initial
determination
and
34
any
supporting
information
to
be
included
in
the
notice.
35
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3.
The
commissioner
may
determine
that
a
request
is
1
eligible
for
expedited
external
review,
notwithstanding
a
2
health
carrier’s
initial
determination
that
the
request
is
3
not
eligible.
In
making
a
determination,
the
commissioner’s
4
decision
shall
be
made
in
accordance
with
the
terms
of
the
5
covered
person’s
health
benefit
plan
and
shall
be
subject
to
6
all
applicable
provisions
of
this
chapter.
The
commissioner
7
shall
make
a
determination
pursuant
to
this
subsection
as
8
expeditiously
as
possible.
9
4.
a.
Upon
receipt
of
notice
from
a
health
carrier
10
that
a
request
is
eligible
for
expedited
external
review
or
11
upon
a
determination
by
the
commissioner
that
a
request
is
12
eligible
for
expedited
external
review,
the
commissioner
shall
13
immediately
assign
an
independent
review
organization
from
the
14
list
of
approved
independent
review
organizations
maintained
by
15
the
commissioner
to
conduct
the
expedited
external
review.
The
16
commissioner
shall
then
immediately
notify
the
health
carrier
17
and
the
covered
person
or
the
covered
person’s
authorized
18
representative
of
the
name
of
the
assigned
independent
review
19
organization.
20
b.
The
assignment
of
an
independent
review
organization
21
shall
be
done
on
a
random
basis
among
those
approved
22
independent
review
organizations
qualified
to
conduct
the
23
particular
external
review
based
on
the
nature
of
the
health
24
care
service
that
is
the
subject
of
the
adverse
determination
25
or
final
adverse
determination
and
other
circumstances,
26
including
conflict
of
interest
concerns.
27
5.
Upon
receiving
notice
of
the
independent
review
28
organization
assigned
to
conduct
the
expedited
external
review,
29
the
health
carrier
shall
provide
or
transmit
all
necessary
30
documents
and
information
considered
in
making
the
adverse
31
determination
or
final
adverse
determination
to
the
independent
32
review
organization
electronically
or
by
telephone
or
facsimile
33
or
any
other
available
expeditious
method.
34
6.
The
independent
review
organization
is
not
bound
35
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by
any
decisions
or
conclusions
reached
during
the
health
1
carrier’s
internal
grievance
process.
The
independent
review
2
organization
shall
consider
the
documents
and
information
3
provided
by
the
health
carrier,
and
to
the
extent
the
4
information
or
documents
are
available
and
the
independent
5
review
organization
considers
them
appropriate,
shall
consider
6
the
following
in
reaching
a
decision:
7
a.
The
covered
person’s
pertinent
medical
records.
8
b.
The
treating
health
care
professional’s
recommendation.
9
c.
Consulting
reports
from
appropriate
health
care
10
professionals
and
other
documents
submitted
by
the
health
11
carrier,
covered
person
or
the
covered
person’s
authorized
12
representative,
or
the
covered
person’s
treating
physician
or
13
other
health
care
professional.
14
d.
The
terms
of
coverage
under
the
covered
person’s
health
15
benefit
plan
with
the
health
carrier,
to
ensure
that
the
16
independent
review
organization’s
decision
is
not
contrary
to
17
the
terms
of
coverage
under
the
covered
person’s
health
benefit
18
plan
with
the
health
carrier.
19
e.
The
most
appropriate
practice
guidelines,
which
shall
20
include
applicable
evidence-based
standards
and
may
include
any
21
other
practice
guidelines
developed
by
the
federal
government,
22
national
or
professional
medical
societies,
boards,
and
23
associations.
24
f.
Any
applicable
clinical
review
criteria
developed
and
25
used
by
the
health
carrier.
26
g.
The
opinion
of
the
independent
review
organization’s
27
clinical
reviewer
after
considering
the
information
or
28
documents
described
in
paragraphs
“a”
through
“f”
to
the
extent
29
the
information
or
documents
are
available
and
the
clinical
30
reviewer
considers
them
relevant.
31
7.
a.
As
expeditiously
as
the
covered
person’s
medical
32
condition
or
circumstances
require,
but
in
no
event
more
than
33
seventy-two
hours
after
the
date
of
receipt
of
an
eligible
34
request
for
expedited
external
review,
the
assigned
independent
35
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H.F.
_____
review
organization
shall
do
all
of
the
following:
1
(1)
Make
a
decision
to
uphold
or
reverse
the
adverse
2
determination
or
final
adverse
determination
of
the
health
3
carrier.
4
(2)
Notify
the
covered
person
or
the
covered
person’s
5
authorized
representative,
the
health
carrier,
and
the
6
commissioner
of
its
decision.
7
b.
If
the
notice
given
by
the
independent
review
8
organization
pursuant
to
paragraph
“a”
was
not
in
writing,
9
within
forty-eight
hours
after
providing
that
notice,
10
the
independent
review
organization
shall
provide
written
11
confirmation
of
the
decision
to
the
covered
person
or
the
12
covered
person’s
authorized
representative,
the
health
carrier,
13
and
the
commissioner
that
includes
the
information
set
forth
in
14
section
514J.107,
subsection
13,
paragraph
“b”
.
15
c.
Upon
receipt
of
the
notice
of
decision
by
an
independent
16
review
organization
pursuant
to
paragraph
“a”
reversing
the
17
adverse
determination
or
final
adverse
determination,
the
18
health
carrier
shall
immediately
approve
the
coverage
that
19
was
the
subject
of
the
adverse
determination
or
final
adverse
20
determination.
21
Sec.
9.
NEW
SECTION
.
514J.109
External
review
of
22
experimental
or
investigational
treatment
adverse
determinations.
23
1.
Within
four
months
after
the
date
of
receipt
of
a
notice
24
of
an
adverse
determination
or
final
adverse
determination
that
25
involves
a
denial
of
coverage
based
on
a
determination
that
26
the
health
care
service
or
treatment
recommended
or
requested
27
is
experimental
or
investigational,
a
covered
person
or
the
28
covered
person’s
authorized
representative
may
file
a
request
29
for
external
review
with
the
commissioner.
30
2.
Within
one
business
day
after
the
date
of
receipt
of
the
31
request,
the
commissioner
shall
notify
the
health
carrier
of
32
the
request.
33
3.
Within
five
business
days
following
the
date
of
receipt
34
of
notice
of
a
request
for
external
review
pursuant
to
this
35
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_____
section,
the
health
carrier
shall
complete
a
preliminary
review
1
of
the
request
to
determine
whether:
2
a.
The
individual
is
or
was
a
covered
person
under
the
3
health
benefit
plan
at
the
time
the
health
care
service
or
4
treatment
was
recommended
or
requested.
5
b.
The
recommended
or
requested
health
care
service
or
6
treatment
that
is
the
subject
of
the
adverse
determination
or
7
final
adverse
determination
meets
the
following
conditions:
8
(1)
Is
a
covered
benefit
under
the
covered
person’s
health
9
benefit
plan
except
for
the
health
carrier’s
determination
that
10
the
service
or
treatment
is
experimental
or
investigational
for
11
a
particular
medical
condition.
12
(2)
Is
not
explicitly
listed
as
an
excluded
benefit
under
13
the
covered
person’s
health
benefit
plan
with
the
health
14
carrier.
15
c.
The
covered
person’s
treating
physician
has
certified
16
that
one
of
the
following
situations
is
applicable:
17
(1)
Standard
health
care
services
or
treatments
have
18
not
been
effective
in
improving
the
condition
of
the
covered
19
person.
20
(2)
Standard
health
care
services
or
treatments
are
not
21
medically
appropriate
for
the
covered
person.
22
(3)
There
is
no
available
standard
health
care
service
or
23
treatment
covered
by
the
health
carrier
that
is
more
beneficial
24
than
the
recommended
or
requested
health
care
service
or
25
treatment
sought.
26
d.
The
covered
person’s
treating
physician
has
certified
in
27
writing
one
of
the
following:
28
(1)
That
the
recommended
or
requested
health
care
service
29
or
treatment
that
is
the
subject
of
the
adverse
determination
30
or
final
adverse
determination
is
likely
to
be
more
beneficial
31
to
the
covered
person,
in
the
physician’s
opinion,
than
any
32
available
standard
health
care
services
or
treatments.
33
(2)
The
physician
is
a
licensed,
board-certified,
or
34
board-eligible
physician
qualified
to
practice
in
the
area
of
35
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medicine
appropriate
to
treat
the
covered
person’s
condition,
1
and
that
scientifically
valid
studies
using
accepted
protocols
2
demonstrate
that
the
health
care
service
or
treatment
3
recommended
or
requested
that
is
the
subject
of
the
adverse
4
determination
or
final
adverse
determination
is
likely
to
5
be
more
beneficial
to
the
covered
person
than
any
available
6
standard
health
care
services
or
treatments.
7
e.
The
covered
person
or
the
covered
person’s
authorized
8
representative
has
exhausted
the
health
carrier’s
internal
9
grievance
process,
unless
the
covered
person
or
the
covered
10
person’s
authorized
representative
is
not
required
to
exhaust
11
the
health
carrier’s
internal
grievance
process
pursuant
to
12
section
514J.106
or
514J.108.
13
f.
The
covered
person
or
the
covered
person’s
authorized
14
representative
has
provided
all
the
information
and
forms
15
required
by
the
commissioner
that
are
necessary
to
process
an
16
external
review
pursuant
to
this
section.
17
4.
Within
one
business
day
after
completion
of
the
18
preliminary
review
pursuant
to
subsection
3,
the
health
19
carrier
shall
notify
the
commissioner
and
the
covered
person
20
or
the
covered
person’s
authorized
representative
in
writing
21
whether
the
request
is
complete
and
whether
the
request
is
22
eligible
for
external
review
pursuant
to
this
section.
If
the
23
request
is
not
complete,
the
health
carrier
shall
notify
the
24
commissioner
and
the
covered
person
or
the
covered
person’s
25
authorized
representative
in
writing
and
include
in
the
notice
26
what
information
or
materials
are
needed
to
make
the
request
27
complete.
If
the
request
is
not
eligible
for
external
review,
28
the
health
carrier
shall
notify
the
covered
person
or
the
29
covered
person’s
authorized
representative
and
the
commissioner
30
in
writing
and
include
in
the
notice
the
reasons
for
its
31
ineligibility.
32
5.
The
commissioner
may
specify
by
rule
the
form
required
33
for
the
health
carrier’s
notice
of
initial
determination
and
34
any
supporting
information
to
be
included
in
the
notice.
The
35
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notice
of
initial
determination
shall
include
a
statement
1
informing
the
covered
person
or
the
covered
person’s
authorized
2
representative
that
a
health
carrier’s
initial
determination
3
that
the
external
review
request
is
ineligible
for
review
may
4
be
appealed
to
the
commissioner.
5
6.
The
commissioner
may
determine
that
a
request
is
eligible
6
for
external
review
pursuant
to
this
section,
notwithstanding
7
a
health
carrier’s
initial
determination
that
the
request
8
is
ineligible,
and
require
that
it
be
referred
for
external
9
review.
In
making
this
determination,
the
commissioner’s
10
decision
shall
be
made
in
accordance
with
the
terms
of
the
11
covered
person’s
health
benefit
plan
and
shall
be
subject
to
12
all
applicable
provisions
of
this
chapter.
13
7.
Within
one
business
day
after
receipt
of
the
notice
14
from
the
health
carrier
that
the
external
review
request
is
15
eligible
for
external
review
or
upon
a
determination
by
the
16
commissioner
that
a
request
is
eligible
for
external
review,
17
the
commissioner
shall
do
all
of
the
following:
18
a.
Assign
an
independent
review
organization
from
the
list
19
of
approved
independent
review
organizations
maintained
by
the
20
commissioner
and
notify
the
health
carrier
of
the
name
of
the
21
assigned
independent
review
organization.
22
b.
Notify
the
covered
person
or
the
covered
person’s
23
authorized
representative
in
writing
of
the
request’s
24
eligibility
and
acceptance
for
external
review
and
the
25
name
of
the
assigned
independent
review
organization
and
26
that
the
covered
person
or
the
covered
person’s
authorized
27
representative
may
submit
in
writing
to
the
independent
review
28
organization,
within
five
business
days
following
the
date
29
of
receipt
of
such
notice,
additional
information
that
the
30
independent
review
organization
shall
consider
when
conducting
31
the
external
review.
The
independent
review
organization
32
may,
in
the
organization’s
discretion,
accept
and
consider
33
additional
information
submitted
by
the
covered
person
or
the
34
covered
person’s
authorized
representative
after
five
business
35
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days.
1
8.
Within
one
business
day
after
receipt
of
the
notice
2
of
assignment
to
conduct
the
external
review,
the
assigned
3
independent
review
organization
shall
select
one
or
more
4
clinical
reviewers,
as
it
determines
is
appropriate
pursuant
to
5
subsection
9
to
conduct
the
external
review.
6
9.
In
selecting
clinical
reviewers,
the
independent
review
7
organization
shall
select
physicians
or
other
health
care
8
professionals
who
meet
the
minimum
qualifications
described
in
9
this
chapter
and,
through
clinical
experience
in
the
past
three
10
years,
are
experts
in
the
treatment
of
the
covered
person’s
11
condition
and
knowledgeable
about
the
recommended
or
requested
12
health
care
service
or
treatment
that
is
the
subject
of
the
13
adverse
determination
or
the
final
adverse
determination.
14
Neither
the
covered
person
or
the
covered
person’s
authorized
15
representative
nor
the
health
carrier
shall
choose
or
control
16
the
choice
of
the
clinical
reviewers
selected
to
conduct
the
17
external
review.
18
10.
Each
clinical
reviewer
selected
shall
provide
a
written
19
opinion
to
the
independent
review
organization
regarding
20
whether
the
recommended
or
requested
health
care
service
or
21
treatment
should
be
covered.
Each
clinical
reviewer
shall
22
review
all
of
the
information
and
documents
received
and
any
23
other
information
submitted
in
writing
by
the
covered
person
or
24
the
covered
person’s
authorized
representative.
In
reaching
25
an
opinion,
a
clinical
reviewer
is
not
bound
by
any
decisions
26
or
conclusions
reached
during
the
health
carrier’s
internal
27
grievance
process.
28
11.
Within
five
business
days
after
receipt
of
notice
of
the
29
assignment
of
the
independent
review
organization,
the
health
30
carrier
shall
provide
to
the
independent
review
organization
31
the
documents
and
any
information
considered
in
making
the
32
adverse
determination
or
the
final
adverse
determination.
33
Failure
by
the
health
carrier
to
provide
the
documents
and
34
information
within
the
time
specified
shall
not
delay
the
35
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conduct
of
the
external
review.
1
12.
If
the
health
carrier
fails
to
provide
the
documents
2
and
information
within
the
time
specified,
the
independent
3
review
organization
may
terminate
the
external
review
and
4
make
a
decision
to
reverse
the
adverse
determination
or
final
5
adverse
determination.
Within
one
business
day
after
making
6
such
a
decision,
the
independent
review
organization
shall
7
notify
the
covered
person
or
the
covered
person’s
authorized
8
representative,
the
health
carrier,
and
the
commissioner.
9
13.
Within
one
business
day
after
the
receipt
of
any
10
information
submitted
by
the
covered
person
or
the
covered
11
person’s
authorized
representative,
the
independent
review
12
organization
shall
forward
the
information
to
the
health
13
carrier.
Upon
receipt
of
the
forwarded
information,
the
health
14
carrier
may
reconsider
its
adverse
determination
or
final
15
adverse
determination
that
is
the
subject
of
the
external
16
review.
17
a.
Reconsideration
by
the
health
carrier
of
its
adverse
18
determination
or
final
adverse
determination
shall
not
delay
or
19
terminate
the
external
review.
The
external
review
shall
only
20
be
terminated
if
the
health
carrier
decides,
upon
completion
21
of
its
reconsideration,
to
reverse
its
determination
and
22
provide
coverage
or
payment
for
the
recommended
or
requested
23
health
care
service
or
treatment
that
is
the
subject
of
the
24
determination.
25
b.
Within
one
business
day
after
making
a
decision
to
26
reverse
its
determination,
the
health
carrier
shall
notify
27
the
covered
person
or
the
covered
person’s
authorized
28
representative,
the
independent
review
organization,
and
the
29
commissioner
in
writing
of
its
decision.
The
independent
30
review
organization
shall
terminate
the
external
review
upon
31
receipt
of
such
notice
from
the
health
carrier.
32
14.
a.
Within
twenty
days
after
being
selected
to
conduct
33
the
external
review,
each
clinical
reviewer
shall
provide
34
an
opinion
to
the
assigned
independent
review
organization
35
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regarding
whether
the
recommended
or
requested
health
care
1
service
or
treatment
should
be
covered
pursuant
to
this
2
section.
3
b.
Each
clinical
reviewer’s
opinion
shall
be
in
writing
and
4
include
the
following
information:
5
(1)
A
description
of
the
covered
person’s
medical
6
condition.
7
(2)
A
description
of
the
indicators
relevant
to
determining
8
whether
there
is
sufficient
evidence
to
demonstrate
that
the
9
recommended
or
requested
health
care
service
or
treatment
is
10
likely
to
be
more
beneficial
to
the
covered
person
than
any
11
available
standard
health
care
services
or
treatments
and
that
12
the
adverse
risks
of
the
recommended
or
requested
health
care
13
service
or
treatment
would
not
be
substantially
increased
over
14
those
of
available
standard
health
care
services
or
treatments.
15
(3)
A
description
and
analysis
of
any
medical
or
scientific
16
evidence
considered
in
reaching
the
opinion.
17
(4)
A
description
and
analysis
of
any
applicable
18
evidence-based
standards.
19
(5)
Information
on
whether
the
reviewer’s
rationale
for
20
the
opinion
is
based
on
either
of
the
factors
described
in
21
subsection
15,
paragraph
“e”
.
22
15.
In
addition
to
the
documents
and
information
provided,
23
each
clinical
reviewer,
to
the
extent
the
information
or
24
documents
are
available
and
the
reviewer
considers
them
25
appropriate,
shall
consider
all
of
the
following
in
reaching
26
an
opinion:
27
a.
The
covered
person’s
pertinent
medical
records.
28
b.
The
treating
physician’s
recommendation
or
request.
29
c.
Consulting
reports
from
appropriate
health
care
30
professionals
and
other
documents
submitted
by
the
health
31
carrier,
the
covered
person
or
the
covered
person’s
authorized
32
representative,
or
the
covered
person’s
treating
physician
or
33
other
health
care
professional.
34
d.
The
terms
of
coverage
under
the
covered
person’s
health
35
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benefit
plan
with
the
health
carrier
to
ensure
that,
but
1
for
the
health
carrier’s
determination
that
the
recommended
2
or
requested
health
care
service
or
treatment
that
is
the
3
subject
of
the
opinion
is
experimental
or
investigational,
the
4
reviewer’s
opinion
is
not
contrary
to
the
terms
of
coverage
5
under
the
covered
person’s
health
benefit
plan
with
the
health
6
carrier.
7
e.
Whether
either
of
the
following
factors
is
applicable:
8
(1)
The
recommended
or
requested
health
care
service
or
9
treatment
has
been
approved
by
the
federal
food
and
drug
10
administration,
if
applicable,
for
the
condition.
11
(2)
Medical
or
scientific
evidence
or
evidence-based
12
standards
demonstrate
that
the
expected
benefits
of
the
13
recommended
or
requested
health
care
service
or
treatment
is
14
likely
to
be
more
beneficial
to
the
covered
person
than
any
15
available
standard
health
care
service
or
treatment
and
the
16
adverse
risks
of
the
recommended
or
requested
health
care
17
service
or
treatment
would
not
be
substantially
increased
over
18
those
of
available
standard
health
care
services
or
treatments.
19
16.
a.
If
a
majority
of
the
clinical
reviewers
opine
that
20
the
recommended
or
requested
health
care
service
or
treatment
21
should
be
covered,
the
independent
review
organization
shall
22
make
a
decision
to
reverse
the
health
carrier’s
adverse
23
determination
or
final
adverse
determination.
24
b.
If
a
majority
of
the
clinical
reviewers
opine
that
the
25
recommended
or
requested
health
care
service
or
treatment
26
should
not
be
covered,
the
independent
review
organization
27
shall
make
a
decision
to
uphold
the
health
carrier’s
adverse
28
determination
or
final
adverse
determination.
29
c.
If
the
clinical
reviewers
are
evenly
split
as
to
whether
30
the
recommended
or
requested
health
care
service
or
treatment
31
should
be
covered,
the
independent
review
organization
shall
32
obtain
the
opinion
of
an
additional
clinical
reviewer
in
order
33
for
the
independent
review
organization
to
make
a
decision
34
based
on
the
opinions
of
a
majority
of
the
clinical
reviewers.
35
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d.
The
additional
clinical
reviewer
selected
shall
use
the
1
same
information
to
reach
an
opinion
as
the
clinical
reviewers
2
who
have
already
submitted
their
opinions.
3
e.
The
selection
of
an
additional
clinical
reviewer
under
4
this
subsection
shall
not
extend
the
time
within
which
the
5
assigned
independent
review
organization
is
required
to
make
a
6
decision
based
on
the
opinions
of
the
clinical
reviewers
for
7
the
external
review.
8
17.
Within
twenty
days
after
it
receives
the
opinion
9
of
each
clinical
reviewer,
the
assigned
independent
review
10
organization
shall
make
a
decision
based
on
the
opinions
of
11
the
clinical
reviewer
or
reviewers,
to
uphold
or
reverse
the
12
adverse
determination
or
final
adverse
determination
of
the
13
health
carrier
and
provide
written
notice
of
the
decision
14
to
the
covered
person
or
the
covered
person’s
authorized
15
representative,
the
health
carrier,
and
the
commissioner.
16
18.
a.
A
covered
person
or
the
covered
person’s
authorized
17
representative
may
make
a
written
or
oral
request
to
the
18
commissioner
for
an
expedited
external
review
of
the
adverse
19
determination
or
final
adverse
determination
pursuant
to
20
this
subsection
if
the
covered
person’s
treating
physician
21
certifies,
in
writing,
that
the
recommended
or
requested
22
health
care
service
or
treatment
that
is
the
subject
of
the
23
request
would
be
significantly
less
effective
if
not
promptly
24
initiated.
25
(1)
Upon
receipt
of
a
request
for
an
expedited
external
26
review
pursuant
to
this
subsection,
the
commissioner
shall
27
immediately
notify
the
health
carrier.
28
(2)
Upon
receipt
of
notice
of
the
request
for
expedited
29
external
review,
the
health
carrier
shall
immediately
determine
30
whether
the
request
is
eligible
for
external
review
as
31
provided
in
subsection
3,
paragraphs
“a”
through
“f”
,
and
shall
32
immediately
issue
a
notice
of
initial
determination
informing
33
the
commissioner
and
the
covered
person
or
the
covered
person’s
34
authorized
representative
of
its
eligibility
determination.
35
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The
notice
of
initial
determination
of
eligibility
issued
by
a
1
health
carrier
shall
include
a
statement
informing
the
covered
2
person
or
the
covered
person’s
authorized
representative
that
3
the
health
carrier’s
initial
determination
that
the
external
4
review
request
is
ineligible
for
expedited
external
review
may
5
be
appealed
to
the
commissioner.
6
(3)
The
commissioner
may
determine
that
a
request
is
7
eligible
for
external
review,
notwithstanding
a
health
8
carrier’s
initial
determination
that
the
request
is
not
9
eligible,
and
refer
the
request
for
external
review.
In
making
10
this
determination,
the
commissioner’s
decision
shall
be
made
11
in
accordance
with
the
terms
of
the
covered
person’s
health
12
benefit
plan
and
shall
be
subject
to
all
applicable
provisions
13
of
this
chapter.
14
b.
(1)
Upon
receipt
of
the
notice
of
initial
determination
15
that
the
request
is
eligible
for
expedited
external
review
16
or
upon
a
determination
by
the
commissioner
that
the
request
17
is
eligible
for
expedited
external
review,
the
commissioner
18
shall
immediately
assign
an
independent
review
organization
19
to
conduct
the
expedited
external
review,
from
the
list
of
20
approved
independent
review
organizations
maintained
by
the
21
commissioner,
and
notify
the
health
carrier
of
the
name
of
the
22
assigned
independent
review
organization.
23
(2)
Upon
receipt
of
notice
of
the
independent
review
24
organization
assigned
to
conduct
an
expedited
external
review,
25
the
health
carrier
shall
provide
or
transmit
all
necessary
26
documents
and
information
considered
in
making
the
adverse
27
determination
or
final
adverse
determination
to
the
independent
28
review
organization
electronically
or
by
telephone
or
facsimile
29
or
any
other
available
expeditious
method.
30
(3)
A
clinical
reviewer
or
clinical
reviewers
shall
be
31
selected
immediately
by
the
independent
review
organization
and
32
shall
provide
an
opinion
orally
or
in
writing
to
the
assigned
33
independent
review
organization
as
expeditiously
as
the
covered
34
person’s
medical
condition
or
circumstances
require,
but
in
no
35
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event
more
than
five
calendar
days
after
being
selected.
If
1
the
opinion
provided
was
not
in
writing,
within
forty-eight
2
hours
following
the
date
the
opinion
was
provided,
the
clinical
3
reviewer
shall
provide
written
confirmation
of
the
opinion
to
4
the
assigned
independent
review
organization
and
include
all
5
required
information
in
support
of
the
opinion.
6
c.
Within
forty-eight
hours
after
the
date
of
receipt
7
of
the
opinion
of
each
clinical
reviewer,
the
assigned
8
independent
review
organization
shall
make
a
decision
based
9
on
the
opinions
of
the
clinical
reviewer
or
reviewers
as
to
10
whether
to
reverse
or
uphold
the
adverse
determination
or
11
final
adverse
determination
and
provide
notice
of
the
decision
12
orally
or
in
writing
to
the
covered
person
or
the
covered
13
person’s
authorized
representative,
the
health
carrier,
and
14
the
commissioner.
If
the
notice
was
provided
orally,
within
15
forty-eight
hours
after
the
date
of
providing
that
notice,
16
the
independent
review
organization
shall
provide
written
17
confirmation
of
the
decision
to
the
covered
person
or
the
18
covered
person’s
authorized
representative,
the
health
carrier,
19
and
the
commissioner.
20
d.
The
independent
review
organization
shall
include
in
the
21
notice
of
its
decision
all
of
the
following:
22
(1)
A
general
description
of
the
reason
for
the
request
for
23
an
expedited
external
review.
24
(2)
The
written
opinion
of
each
clinical
reviewer,
25
including
the
recommendation
of
each
clinical
reviewer
as
26
to
whether
the
recommended
or
requested
health
care
service
27
or
treatment
should
be
covered
and
the
rationale
for
the
28
reviewer’s
recommendation.
29
(3)
The
date
the
independent
review
organization
was
30
assigned
by
the
commissioner
to
conduct
the
expedited
external
31
review.
32
(4)
The
date
the
expedited
external
review
was
conducted.
33
(5)
The
date
of
its
decision.
34
(6)
The
principal
reason
or
reasons
for
its
decision.
35
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(7)
The
rationale
for
its
decision.
1
19.
Upon
receipt
of
notice
of
a
decision
of
the
independent
2
review
organization
reversing
an
adverse
determination
or
final
3
adverse
determination,
the
health
carrier
shall
immediately
4
approve
coverage
of
the
recommended
or
requested
health
care
5
service
or
treatment
that
was
the
subject
of
the
determination.
6
Sec.
10.
NEW
SECTION
.
514J.110
Effect
of
external
review
7
decision.
8
1.
An
external
review
decision
pursuant
to
this
chapter
is
9
binding
on
the
health
carrier
except
to
the
extent
the
health
10
carrier
has
other
remedies
available
under
applicable
Iowa
law.
11
The
external
review
process
shall
not
be
considered
a
contested
12
case
under
chapter
17A.
13
2.
a.
A
covered
person
or
the
covered
person’s
authorized
14
representative
may
appeal
the
external
review
decision
made
by
15
an
independent
review
organization
by
filing
a
petition
for
16
judicial
review
either
in
Polk
county
district
court
or
in
17
the
district
court
in
the
county
in
which
the
covered
person
18
resides.
The
petition
for
judicial
review
must
be
filed
19
within
fifteen
business
days
after
the
issuance
of
the
review
20
decision.
The
petition
shall
name
the
covered
person
or
the
21
covered
person’s
authorized
representative,
or
the
person’s
22
health
care
provider
as
the
petitioner.
The
respondent
23
shall
be
the
health
carrier.
The
petition
shall
not
name
the
24
independent
review
organization
as
a
party.
25
b.
The
commissioner
shall
not
be
named
as
a
respondent
26
unless
the
petitioner
alleges
action
or
inaction
by
the
27
commissioner
under
the
standards
articulated
in
section
28
17A.19,
subsection
10.
Allegations
against
the
commissioner
29
under
section
17A.19,
subsection
10,
shall
be
stated
with
30
particularity.
The
commissioner
may,
upon
motion,
intervene
in
31
the
judicial
review
proceeding.
The
findings
of
fact
by
the
32
independent
review
organization
conducting
the
external
review
33
are
conclusive
and
binding
on
appeal.
34
3.
The
health
carrier
shall
follow
and
comply
with
the
35
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H.F.
_____
decision
of
the
court
on
appeal.
The
health
carrier
or
1
treating
health
care
provider
shall
not
be
subject
to
any
2
penalties,
sanctions,
or
award
of
damages
for
following
and
3
complying
in
good
faith
with
the
external
review
decision
of
4
the
independent
review
organization
or
the
decision
of
the
5
court
on
appeal.
6
4.
The
covered
person
or
the
covered
person’s
authorized
7
representative
may
bring
an
action
in
Polk
county
district
8
court
or
in
the
district
court
in
the
county
in
which
the
9
covered
person
resides
to
enforce
the
external
review
decision
10
of
the
independent
review
organization
or
the
decision
of
the
11
court
on
appeal.
12
5.
A
covered
person
or
the
covered
person’s
authorized
13
representative
shall
not
file
a
subsequent
request
for
external
14
review
involving
any
determination
for
which
the
covered
person
15
or
the
covered
person’s
authorized
representative
has
already
16
received
an
external
review
decision.
17
6.
If
a
covered
person
dies
before
the
completion
of
18
the
external
review
process,
the
process
shall
continue
to
19
completion
if
there
is
potential
liability
of
a
health
carrier
20
to
the
estate
of
the
covered
person.
21
7.
a.
If
a
covered
person
who
has
already
received
health
22
care
services
under
a
health
benefit
plan
requests
external
23
review
of
the
plan’s
adverse
determination
or
final
adverse
24
determination
and
changes
to
another
health
benefit
plan
before
25
the
external
review
process
is
completed,
the
health
carrier
26
whose
coverage
was
in
effect
at
the
time
the
health
care
27
service
was
received
is
responsible
for
completing
the
external
28
review
process.
29
b.
If
a
covered
person
who
has
not
yet
received
health
30
care
services
requests
external
review
of
a
health
benefit
31
plan’s
adverse
determination
or
final
adverse
determination
32
and
then
changes
to
another
plan
prior
to
receipt
of
the
33
health
care
services
and
completion
of
the
external
review
34
process,
the
external
review
process
shall
begin
anew
with
the
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H.F.
_____
covered
person’s
current
health
carrier.
In
this
instance,
1
the
external
review
process
shall
be
conducted
as
an
expedited
2
external
review.
3
Sec.
11.
NEW
SECTION
.
514J.111
Approval
of
independent
4
review
organizations.
5
1.
The
commissioner
shall
approve
applications
submitted
by
6
independent
review
organizations
to
conduct
external
reviews
7
under
this
chapter.
The
commissioner
may
retain
an
outside
8
expert
to
perform
reviews
of
such
applications.
9
2.
In
order
to
be
eligible
for
approval
by
the
commissioner
10
to
conduct
external
reviews,
an
independent
review
organization
11
shall
meet
all
of
the
following
requirements:
12
a.
Be
accredited
by
a
nationally
recognized
private
13
accrediting
entity
that
the
commissioner
determines
has
14
independent
review
organization
accreditation
standards
that
15
are
equivalent
to
or
exceed
the
minimum
qualifications
for
16
independent
review
organizations
established
in
this
chapter.
17
b.
Submit
an
application
in
a
form
and
format
as
directed
by
18
the
commissioner.
19
c.
Meet
the
minimum
qualifications
contained
in
section
20
514J.112.
21
3.
The
commissioner
may
approve
independent
review
22
organizations
that
are
not
accredited
by
a
nationally
23
recognized
private
accrediting
entity
if
there
are
no
24
acceptable
nationally
recognized
private
accrediting
entities
25
providing
independent
review
organization
accreditation.
26
4.
The
commissioner
shall
develop
an
application
form
for
27
initially
approving
and
for
reapproving
independent
review
28
organizations
to
conduct
external
reviews.
29
5.
The
commissioner
may
charge
an
initial
application
fee
30
and
a
renewal
fee
as
specified
by
rule.
31
6.
The
approval
of
an
independent
review
organization
to
32
conduct
external
reviews
by
the
commissioner
pursuant
to
this
33
chapter
is
effective
for
two
years,
unless
the
commissioner
34
determines
that
the
independent
review
organization
is
not
35
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H.F.
_____
satisfying
the
minimum
qualifications
of
this
chapter.
If
the
1
commissioner
determines
that
an
independent
review
organization
2
has
lost
its
accreditation
or
no
longer
satisfies
the
minimum
3
requirements
established
under
this
chapter,
the
commissioner
4
shall
terminate
approval
of
the
independent
review
organization
5
to
conduct
external
reviews
and
remove
the
independent
review
6
organization
from
the
list
of
independent
review
organizations
7
approved
to
conduct
external
reviews
that
is
maintained
by
the
8
commissioner.
9
7.
The
commissioner
shall
maintain
a
list
of
currently
10
approved
independent
review
organizations.
11
Sec.
12.
NEW
SECTION
.
514J.112
Minimum
qualifications
for
12
independent
review
organizations.
13
1.
To
be
approved
to
conduct
external
reviews
pursuant
14
to
this
chapter,
an
independent
review
organization
shall
15
have
and
maintain
written
policies
and
procedures
that
govern
16
all
aspects
of
both
the
standard
external
review
process
and
17
the
expedited
external
review
process
and
that
include,
at
a
18
minimum,
all
of
the
following:
19
a.
A
quality
assurance
mechanism
that
does
all
of
the
20
following:
21
(1)
Ensures
that
external
reviews
are
conducted
within
the
22
specified
time
frames
and
that
required
notices
are
provided
23
in
a
timely
manner.
24
(2)
Ensures
the
selection
of
qualified
and
impartial
25
clinical
reviewers
to
conduct
external
reviews
on
behalf
of
26
the
independent
review
organization
and
suitable
matching
of
27
reviewers
to
specific
cases
and
that
the
independent
review
28
organization
employs
or
contracts
with
an
adequate
number
of
29
clinical
reviewers
to
meet
this
objective.
30
(3)
Ensures
the
confidentiality
of
medical
and
treatment
31
records
and
clinical
review
criteria.
32
(4)
Establishes
and
maintains
written
procedures
to
33
ensure
that
the
independent
review
organization
is
unbiased
in
34
addition
to
any
other
procedures
required
under
this
section.
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H.F.
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(5)
Ensures
that
any
person
employed
by
or
under
contract
1
with
the
independent
review
organization
adheres
to
the
2
requirements
of
this
chapter.
3
b.
A
toll-free
telephone
service
to
receive
information
4
related
to
external
reviews
twenty-four
hours
a
day,
seven
days
5
a
week,
that
is
capable
of
accepting,
recording,
or
providing
6
appropriate
instruction
to
incoming
telephone
callers
outside
7
normal
business
hours.
8
c.
An
agreement
and
a
system
to
maintain
required
records
9
and
provide
access
to
those
records
by
the
commissioner.
10
2.
Each
clinical
reviewer
assigned
by
an
independent
review
11
organization
to
conduct
external
reviews
shall
be
a
physician
12
or
other
appropriate
health
care
professional
who
meets
all
of
13
the
following
minimum
qualifications:
14
a.
Is
an
expert
in
the
treatment
of
the
covered
person’s
15
medical
condition
that
is
the
subject
of
the
external
review.
16
b.
Is
knowledgeable
about
the
recommended
or
requested
17
health
care
service
or
treatment
through
recent
or
current
18
actual
clinical
experience
treating
patients
with
the
same
or
19
similar
medical
condition
as
the
covered
person.
20
c.
Holds
a
nonrestricted
license
in
a
state
of
the
United
21
States
and,
for
physicians,
a
current
certification
by
a
22
recognized
American
medical
specialty
board
in
the
area
or
23
areas
appropriate
to
the
subject
of
the
external
review.
24
d.
Has
no
history
of
disciplinary
actions
or
sanctions,
25
including
loss
of
staff
privileges
or
participation
26
restrictions,
that
have
been
taken
or
are
pending
by
any
27
hospital,
governmental
agency
or
unit,
or
regulatory
body
that
28
raise
a
substantial
question
as
to
the
clinical
reviewer’s
29
physical,
mental,
or
professional
competence
or
moral
30
character.
31
3.
An
independent
review
organization
shall
not
own
32
or
control,
be
a
subsidiary
of,
or
in
any
way
be
owned
or
33
controlled
by,
or
exercise
control
with,
a
health
benefit
plan,
34
a
national,
state,
or
local
trade
association
of
health
benefit
35
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_____
H.F.
_____
plans,
or
a
national,
state,
or
local
trade
association
of
1
health
care
providers.
2
4.
Neither
the
independent
review
organization
selected
to
3
conduct
an
external
review
nor
any
clinical
reviewer
assigned
4
by
the
independent
organization
to
conduct
an
external
review
5
shall
have
a
material
professional,
familial,
or
financial
6
conflict
of
interest
with
any
of
the
following:
7
a.
The
health
carrier
that
is
the
subject
of
the
external
8
review.
9
b.
The
covered
person
whose
health
care
service
or
treatment
10
is
the
subject
of
the
external
review
or
the
covered
person’s
11
authorized
representative.
12
c.
Any
officer,
director,
or
management
employee
of
the
13
health
carrier
that
is
the
subject
of
the
external
review.
14
d.
The
health
care
professional
or
the
health
care
15
professional’s
medical
group
or
independent
practice
16
association
recommending
the
health
care
service
or
treatment
17
that
is
the
subject
of
the
external
review.
18
e.
The
facility
at
which
the
recommended
health
care
service
19
or
treatment
would
be
provided.
20
f.
The
developer
or
manufacturer
of
the
principal
drug,
21
device,
procedure,
or
other
therapy
being
recommended
for
the
22
covered
person
whose
health
care
service
treatment
is
the
23
subject
of
the
external
review.
24
5.
In
determining
whether
an
independent
review
25
organization
or
a
clinical
reviewer
of
the
independent
26
review
organization
has
a
material
professional,
familial,
27
or
financial
conflict
of
interest
as
provided
in
subsection
28
4,
the
commissioner
shall
take
into
consideration
situations
29
where
the
independent
review
organization
to
be
assigned
to
30
conduct
an
external
review
of
a
specified
case
or
a
clinical
31
reviewer
to
be
assigned
by
the
independent
review
organization
32
to
conduct
an
external
review
of
a
specified
case
may
have
an
33
apparent
professional,
familial,
or
financial
relationship
or
34
connection
with
a
person
described
in
subsection
4,
but
the
35
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_____
H.F.
_____
characteristics
of
that
relationship
or
connection
are
such
1
that
they
do
not
constitute
a
material
professional,
familial,
2
or
financial
conflict
of
interest
that
would
prohibit
selection
3
of
the
independent
review
organization
or
the
clinical
reviewer
4
to
conduct
the
external
review.
5
6.
a.
An
independent
review
organization
that
is
accredited
6
by
a
nationally
recognized
private
accrediting
entity
that
7
has
independent
review
accreditation
standards
that
the
8
commissioner
has
determined
are
equivalent
to
or
exceed
the
9
minimum
qualifications
of
this
section
shall
be
presumed
to
be
10
in
compliance
with
the
requirements
of
this
section.
11
b.
The
commissioner
shall
initially
and
periodically
review
12
the
standards
of
each
nationally
recognized
private
accrediting
13
entity
that
provides
accreditation
to
independent
review
14
organizations
to
determine
whether
the
accrediting
entity’s
15
standards
are,
and
continue
to
be,
equivalent
to
or
exceed
the
16
minimum
qualifications
established
under
this
section.
The
17
commissioner
may
accept
a
review
of
those
standards
conducted
18
by
the
national
association
of
insurance
commissioners
for
the
19
purpose
of
making
a
determination
under
this
subsection.
20
c.
Upon
request,
a
nationally
recognized
private
accrediting
21
entity
shall
make
its
current
independent
review
organization
22
accreditation
standards
available
to
the
commissioner
or
23
to
the
national
association
of
insurance
commissioners
in
24
order
for
the
commissioner
to
determine
if
the
accrediting
25
entity’s
standards
are
equivalent
to
or
exceed
the
minimum
26
qualifications
established
under
this
section.
The
27
commissioner
may
exclude
consideration
of
accreditation
of
28
independent
review
organizations
by
any
private
accrediting
29
entity
whose
standards
have
not
been
reviewed
by
the
national
30
association
of
insurance
commissioners.
31
Sec.
13.
NEW
SECTION
.
514J.113
Immunity
for
independent
32
review
organizations.
33
An
independent
review
organization,
a
clinical
reviewer
34
working
on
behalf
of
an
independent
review
organization,
or
35
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H.F.
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an
employee,
agent,
or
contractor
of
an
independent
review
1
organization
shall
not
be
liable
in
damages
to
any
person
for
2
any
opinions
rendered
or
acts
or
omissions
performed
within
the
3
scope
of
the
duties
of
the
organization,
the
clinical
reviewer,
4
or
an
employee,
agent,
or
contractor
of
the
organization
under
5
this
chapter
during,
or
upon
completion
of,
an
external
review
6
conducted
pursuant
to
this
chapter,
unless
the
opinion
was
7
rendered
or
the
act
or
omission
was
performed
in
bad
faith
or
8
involved
gross
negligence.
9
Sec.
14.
NEW
SECTION
.
514J.114
External
review
reporting
10
requirements.
11
1.
a.
An
independent
review
organization
assigned
to
12
conduct
an
external
review
shall
maintain
written
records
in
13
the
aggregate
by
state
and
by
health
carrier
of
all
requests
14
for
external
review
for
which
it
conducted
an
external
review
15
during
a
calendar
year.
16
b.
Each
independent
review
organization
required
to
maintain
17
written
records
pursuant
to
this
section
shall
submit
to
the
18
commissioner,
upon
request,
a
report
in
the
format
specified
by
19
the
commissioner.
The
report
shall
include
in
the
aggregate
by
20
state
and
by
health
carrier
all
of
the
following:
21
(1)
The
total
number
of
requests
for
external
review
22
assigned
to
the
independent
review
organization.
23
(2)
The
average
length
of
time
for
resolution
of
each
24
request
for
external
review
assigned
to
the
independent
review
25
organization.
26
(3)
A
summary
of
the
types
of
coverages
or
cases
for
which
27
an
external
review
was
requested,
in
the
format
required
by
the
28
commissioner
by
rule.
29
(4)
Any
other
information
required
by
the
commissioner.
30
c.
The
independent
review
organization
shall
retain
the
31
written
records
for
at
least
three
years.
32
2.
a.
Each
health
carrier
shall
maintain
written
records
33
in
the
aggregate
by
state
and
by
type
of
health
benefit
plan
34
offered
by
the
health
carrier
of
all
requests
for
external
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_____
H.F.
_____
review
that
the
health
carrier
receives
notice
of
from
the
1
commissioner
pursuant
to
this
chapter.
2
b.
Each
health
carrier
required
to
maintain
written
records
3
of
requests
for
external
review
pursuant
to
this
subsection
4
shall
submit
to
the
commissioner,
upon
request,
a
report
in
the
5
format
specified
by
the
commissioner.
The
report
shall
include
6
in
the
aggregate
by
state
and
by
type
of
health
benefit
plan
7
offered
all
of
the
following:
8
(1)
The
total
number
of
requests
for
external
review
of
9
the
health
carrier’s
adverse
determinations
and
final
adverse
10
determinations.
11
(2)
Of
the
total
number
of
requests
for
external
review,
the
12
number
of
requests
determined
eligible
for
external
review.
13
(3)
The
number
of
requests
for
external
review
resolved
14
and,
of
those
resolved,
the
number
resolved
upholding
the
15
adverse
determination
or
final
adverse
determination
of
the
16
health
carrier
and
the
number
resolved
reversing
the
adverse
17
determination
or
final
adverse
determination
of
the
health
18
carrier.
19
(4)
The
number
of
external
reviews
that
were
terminated
as
20
the
result
of
a
reconsideration
by
the
health
carrier
of
its
21
adverse
determination
or
final
adverse
determination
after
the
22
receipt
of
additional
information
from
the
covered
person
or
23
the
covered
person’s
authorized
representative.
24
(5)
Any
other
information
the
commissioner
may
request
or
25
require.
26
c.
The
health
carrier
shall
retain
the
written
records
for
27
at
least
three
years.
28
Sec.
15.
NEW
SECTION
.
514J.115
Expenses
of
external
review.
29
The
health
carrier
against
which
a
request
for
a
standard
30
external
review
or
an
expedited
external
review
is
filed
shall
31
pay
the
costs
of
retaining
an
independent
review
organization
32
to
conduct
the
external
review.
33
Sec.
16.
NEW
SECTION
.
514J.116
Disclosure
requirements.
34
1.
Each
health
carrier
shall
include
a
description
of
35
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_____
H.F.
_____
the
external
review
procedures
contained
in
this
chapter
in
1
or
attached
to
any
policy,
certificate,
membership
booklet,
2
outline
of
coverage,
or
other
evidence
of
coverage
that
is
3
provided
to
a
covered
person.
The
description
shall
be
in
a
4
format
prescribed
by
the
commissioner
by
rule.
5
2.
The
description
required
by
subsection
1
shall
include
6
a
statement
that
informs
the
covered
person
of
the
right
of
7
the
covered
person
to
file
a
request
for
an
external
review
8
of
an
adverse
determination
or
final
adverse
determination
of
9
the
health
carrier
with
the
commissioner.
The
statement
shall
10
explain
that
external
review
is
available
when
the
adverse
11
determination
or
final
adverse
determination
involves
an
issue
12
of
medical
necessity,
appropriateness,
health
care
setting,
13
level
of
care,
or
effectiveness.
The
statement
shall
include
14
the
telephone
number
and
address
of
the
commissioner.
The
15
statement
shall
also
inform
the
covered
person
that
when
filing
16
a
request
for
external
review,
the
covered
person
will
be
17
required
to
authorize
the
release
of
any
medical
records
of
18
the
covered
person
that
may
be
required
to
be
reviewed
for
the
19
purpose
of
reaching
a
decision
on
the
request
for
external
20
review.
21
Sec.
17.
NEW
SECTION
.
514J.117
Rulemaking
authority.
22
The
commissioner
may
adopt
rules
pursuant
to
chapter
17A
to
23
carry
out
the
provisions
of
this
chapter.
24
Sec.
18.
NEW
SECTION
.
514J.118
Severability.
25
If
any
provision
of
this
chapter,
or
the
application
of
the
26
provision
to
any
person
or
circumstance
is
held
invalid,
the
27
remainder
of
the
chapter,
and
the
application
of
the
provision
28
to
persons
or
circumstances
other
than
those
to
which
it
is
29
held
invalid,
shall
not
be
affected.
30
Sec.
19.
NEW
SECTION
.
514J.119
Penalties.
31
A
person
who
fails
to
comply
with
the
provisions
of
this
32
chapter
or
the
rules
adopted
pursuant
to
this
chapter
is
33
subject
to
the
penalties
provided
under
chapter
507B.
34
Sec.
20.
NEW
SECTION
.
514J.120
Applicability.
35
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_____
H.F.
_____
1.
This
chapter
applies
to
all
requests
for
external
review
1
filed
on
or
after
July
1,
2011.
2
2.
Section
514J.116
applies
to
all
health
benefit
plans
3
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
4
state
on
or
after
July
1,
2011.
5
Sec.
21.
REPEAL.
Sections
514J.1
through
514J.15,
Code
6
2011,
are
repealed.
7
Sec.
22.
TRANSITION
PROVISION
——
APPLICABILITY
TO
PRIOR
8
REQUESTS.
Sections
514J.1
through
514J.15,
Code
2011,
are
9
applicable
to
all
requests
for
external
review
filed
prior
to
10
July
1,
2011.
11
EXPLANATION
12
This
bill
adds
new
provisions
in
Code
chapter
514J,
13
which
provides
procedures
for
external
review
of
adverse
14
determinations
made
by
health
carriers,
as
required
by
the
15
federal
Patient
Protection
and
Affordable
Care
Act,
as
amended
16
by
the
federal
Health
Care
and
Education
Reconciliation
Act
17
of
2010,
which
amends
the
Public
Health
Service
Act.
The
new
18
provisions
apply
to
all
requests
for
external
review
filed
on
19
or
after
July
1,
2011.
The
bill
repeals
the
current
provisions
20
in
Code
chapter
514J
relating
to
the
external
review
of
health
21
care
coverage
decisions.
22
An
“adverse
determination”
is
a
determination
by
a
health
23
carrier
that
payment
for
a
health
care
service
that
is
a
24
covered
benefit
under
a
health
benefit
plan
is
being
denied,
25
reduced,
or
terminated
because
the
health
care
service
does
26
not
meet
the
carrier’s
requirements
for
medical
necessity,
27
appropriateness,
health
care
setting,
level
of
care,
or
28
effectiveness.
A
“final
adverse
determination”
is
an
adverse
29
determination
involving
a
covered
benefit
that
has
been
upheld
30
by
a
health
carrier
at
the
completion
of
the
health
carrier’s
31
internal
grievance
process.
32
The
bill
allows
a
covered
person
under
a
health
benefit
plan
33
or
the
covered
person’s
authorized
representative
to
request
34
an
external
review
of
the
health
carrier’s
determination
after
35
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_____
H.F.
_____
receiving
a
final
adverse
determination
or
sooner,
after
1
receiving
an
adverse
determination,
if
the
covered
person
has
2
a
medical
condition
where
the
time
frame
for
completion
of
3
that
internal
review
would
jeopardize
the
person’s
life
or
4
health
or
ability
to
regain
maximum
function,
or
the
adverse
5
determination
is
that
the
requested
health
care
service
is
6
experimental
or
investigational
and
the
effectiveness
of
the
7
treatment
will
be
significantly
less
effective
if
not
promptly
8
initiated.
The
bill
provides
procedures
for
a
standard
9
external
review
or
an
expedited
external
review.
10
Pursuant
to
a
request
for
standard
external
review,
the
11
health
carrier
must
complete
a
preliminary
review
to
determine
12
if
the
request
is
eligible
for
external
review
as
specified
in
13
the
bill
and
report
to
the
commissioner
of
insurance
and
the
14
covered
person.
Even
if
the
health
carrier
determines
that
15
the
request
is
ineligible,
the
commissioner
of
insurance
may
16
determine
that
the
request
is
eligible
for
review.
17
Once
a
request
is
determined
to
be
eligible
for
review,
18
the
commissioner
is
required
to
assign
an
independent
review
19
organization
to
conduct
the
external
review
of
the
adverse
or
20
final
adverse
determination
of
the
health
carrier.
During
the
21
review,
the
carrier
may
reconsider
its
adverse
or
final
adverse
22
determination
and
provide
the
coverage
requested.
If
this
does
23
not
occur,
the
independent
review
organization
selects
clinical
24
reviewers
to
consider
all
pertinent
information
and
within
25
45
days
of
receiving
the
request
for
external
review,
the
26
independent
review
organization
must
provide
written
notice
of
27
its
decision
to
uphold
or
reverse
the
adverse
or
final
adverse
28
determination
of
the
carrier.
Upon
receipt
of
a
decision
of
29
reversal,
the
carrier
must
approve
the
coverage
that
was
the
30
subject
of
the
adverse
or
final
adverse
determination.
31
The
bill
also
provides
a
similar
procedure
for
expedited
32
external
review
of
an
adverse
or
final
adverse
determination
33
that
involves
a
medical
condition
of
the
covered
person
for
34
which
the
time
frame
for
completion
of
the
internal
review
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_____
H.F.
_____
by
the
health
carrier
or
a
standard
external
review
would
1
seriously
jeopardize
the
life
or
health
or
the
ability
to
2
regain
maximum
function
of
the
covered
person.
The
expedited
3
external
review
procedures
provide
that
a
request
for
expedited
4
external
review
can
be
made
by
a
covered
person
orally,
5
and
shortens
the
required
time
frames
for
action
by
the
6
health
carrier,
the
commissioner,
and
the
independent
review
7
organization
in
responding
to
the
request
and
reaching
a
8
decision.
9
The
bill
provides
separate
procedures
for
standard
and
10
expedited
external
reviews
of
adverse
determinations
or
11
final
adverse
determinations
involving
experimental
or
12
investigational
treatment.
In
a
standard
external
review,
if
13
an
independent
review
organization
selects
multiple
clinical
14
reviewers
to
review
the
request,
the
organization
must
make
15
a
decision
to
uphold
or
reverse
an
adverse
or
final
adverse
16
determination
of
a
health
carrier
based
on
the
opinion
of
a
17
majority
of
the
clinical
reviewers.
18
The
bill
allows
a
covered
person
or
the
covered
person’s
19
authorized
representative
to
appeal
the
external
review
20
decision
made
by
an
independent
review
organization
by
filing
a
21
petition
for
judicial
review
in
Polk
county
district
court
or
22
in
the
district
court
in
the
county
where
the
covered
person
23
resides.
Findings
of
fact
made
by
an
independent
review
24
organization
are
conclusive
and
binding
on
appeal.
A
covered
25
person
or
the
covered
person’s
authorized
representative
may
26
also
bring
an
action
in
district
court
to
enforce
an
external
27
review
decision
against
a
carrier.
28
The
bill
includes
requirements
for
the
qualifications
of
an
29
independent
review
organization
to
be
listed
as
eligible
for
30
selection
by
the
commissioner
to
conduct
an
external
review.
31
The
bill
provides
that
independent
review
organizations
and
32
clinical
reviewers
are
not
liable
in
damages
for
any
opinions
33
rendered
in
furtherance
of
their
duties
under
this
new
division
34
unless
rendered
in
bad
faith
or
with
gross
negligence.
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_____
H.F.
_____
Independent
review
organizations
and
health
carriers
are
1
required
to
keep
specified
records
about
external
review
2
requests
involving
them.
The
expense
of
retaining
an
3
independent
review
organization
to
conduct
an
external
review
4
is
assessed
against
the
health
carrier
whose
adverse
or
final
5
adverse
determination
is
being
reviewed.
6
External
review
procedures
must
be
disclosed
by
health
7
carriers
by
including
or
attaching
them
to
the
policies,
8
certificates,
membership
booklets,
outline
of
coverage,
or
9
other
evidence
of
coverage
that
is
provided
to
covered
persons.
10
This
disclosure
requirement
applies
to
all
health
benefit
plans
11
delivered,
issued
for
delivery,
continued,
or
renewed
on
or
12
after
July
1,
2011.
13
The
commissioner
of
insurance
has
the
authority
to
adopt
14
rules
to
carry
out
the
provisions
of
the
new
division
and
the
15
provisions
of
the
new
division
are
severable
if
held
invalid.
16
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