2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 514J - EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS
514J.5 - CERTIFICATION OF REQUEST -- ELIGIBILITY.

        514J.5  CERTIFICATION OF REQUEST -- ELIGIBILITY.
         1.  The commissioner shall have two business days from receipt of
      a request for an external review to certify the request.  The
      commissioner shall certify the request if all of the following
      criteria are satisfied:
         a.  The enrollee was covered by the carrier or organized
      delivery system at the time the service or treatment was proposed or
      received.
         b.  The enrollee has been denied coverage based on a
      determination by the carrier or organized delivery system that the
      proposed or received service or treatment does not meet the
      definition of medical necessity as defined in the carrier's or
      organized delivery system's plan or policy.
         c.  The enrollee, or the enrollee's treating health care
      provider acting on behalf of the enrollee, has exhausted all internal
      appeal mechanisms provided under the carrier's or the organized
      delivery system's plan or policy.
         d.  The written request for external review was filed within
      sixty days of receipt of the coverage decision.
         2.  The commissioner shall notify the enrollee, or the enrollee's
      treating health care provider acting on behalf of the enrollee, and
      the carrier or organized delivery system in writing of the
      certification.
         3.  The carrier or organized delivery system has three business
      days from the date of receipt to contest the commissioner's
      certification decision.  If the commissioner finds that the request
      for external review is not eligible for certification, the
      commissioner, within two business days of the date of the request,
      shall notify the enrollee, or the enrollee's treating health care
      provider acting on behalf of the enrollee, in writing of the reasons
      that the request for external review is not eligible for
      certification.
         If the commissioner finds that the request for external review is
      eligible for certification, notwithstanding the contest by the
      carrier or organized delivery system, the commissioner shall promptly
      notify the carrier or organized delivery system in writing of the
      reasons for upholding the certification.  

         99 Acts, ch 41, §11, 22; 2001 Acts, ch 69, §26; 2002 Acts, ch
      1119, §69
         Referred to in § 514J.7