2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 514F - UTILIZATION AND COST CONTROL
514F.4 - UTILIZATION REVIEW REQUIREMENTS.

        514F.4  UTILIZATION REVIEW REQUIREMENTS.
         1.  A third-party payor which provides health benefits to a
      covered individual residing in this state shall not conduct
      utilization review, either directly or indirectly, under a contract
      with a third-party who does not meet the requirements established for
      accreditation by the utilization review accreditation commission,
      national committee on quality assurance, or another national
      accreditation entity recognized and approved by the commissioner.
         2.  This section does not apply to any utilization review
      performed solely under contract with the federal government for
      review of patients eligible for services under any of the following:
         a.  Title XVIII of the federal Social Security Act.
         b.  The civilian health and medical program of the uniformed
      services.
         c.  Any other federal employee health benefit plan.
         3.  For purposes of this section, unless the context otherwise
      requires:
         a.  "Third-party payor" means:
         (1)  An insurer subject to chapter 509 or 514A.
         (2)  A health service corporation subject to chapter 514.
         (3)  A health maintenance organization subject to chapter 514B.
         (4)  A preferred provider arrangement.
         (5)  A multiple employer welfare arrangement.
         (6)  A third-party administrator.
         (7)  A fraternal benefit society.
         (8)  A plan established pursuant to chapter 509A for public
      employees.
         (9)  Any other benefit program providing payment, reimbursement,
      or indemnification for health care costs for an enrollee or an
      enrollee's eligible dependents.
         b.  "Utilization review" means a program or process by which
      an evaluation is made of the necessity, appropriateness, and
      efficiency of the use of health care services, procedures, or
      facilities given or proposed to be given to an individual within this
      state.  Such evaluation does not apply to requests by an individual
      or provider for a clarification, guarantee, or statement of an
      individual's health insurance coverage or benefits provided under a
      health insurance policy, nor to claims adjudication.  Unless it is
      specifically stated, verification of benefits, preauthorization, or a
      prospective or concurrent utilization review program or process shall
      not be construed as a guarantee or statement of insurance coverage or
      benefits for any individual under a health insurance policy.  

         99 Acts, ch 41, §5