2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 514J - EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS
514J.2 - DEFINITIONS.

        514J.2  DEFINITIONS.
         1.  "Carrier" means an entity subject to the insurance laws
      and regulations of this state, or subject to the jurisdiction of the
      commissioner, performing utilization review, including an insurance
      company offering sickness and accident plans, a health maintenance
      organization, a nonprofit health service corporation, a plan
      established pursuant to chapter 509A for public employees, or any
      other entity providing a plan of health insurance, health care
      benefits, or health care services.
         2.  "Commissioner" means the commissioner of insurance.
         3.  "Coverage decision" means a final adverse decision based
      on medical necessity.  This definition does not include a denial of
      coverage for a service or treatment specifically listed in plan or
      evidence of coverage documents as excluded from coverage, or a denial
      of coverage for a service or treatment that has already been received
      and for which the enrollee has no financial liability.
         4.  "Enrollee" means an individual, or an eligible dependent,
      who receives health care benefits coverage through a carrier or
      organized delivery system.
         5.  "Independent review entity" means a reviewer or entity,
      certified by the commissioner pursuant to section 514J.6.
         6.  "Organized delivery system" means an organized delivery
      system authorized under 1993 Iowa Acts, chapter 158, and licensed by
      the director of public health, and performing utilization review.  

         99 Acts, ch 41, §8, 22; 2007 Acts, ch 137, §11