2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 514J - EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS
514J.7 - EXTERNAL REVIEW.

        514J.7  EXTERNAL REVIEW.
         The external review process shall meet the following criteria:
         1.  The carrier or organized delivery system, within three
      business days of a receipt of an eligible request for an external
      review from the commissioner, or within three business days of
      receipt of the commissioner's denial of the carrier's or organized
      delivery system's contest of the certification of the request under
      section 514J.5, subsection 3, whichever is later, shall do all of the
      following:
         a.  Select an independent review entity from the list
      certified by the commissioner.  The independent review entity shall
      be an expert in the treatment of the medical condition under review.
      The independent review entity shall not be a subsidiary of, or owned
      or controlled by, the carrier or organized delivery system, or owned
      or controlled by a trade association of carriers or organized
      delivery systems of which the carrier or organized delivery system is
      a member.
         b.  Notify in writing the enrollee, and the enrollee's
      treating health care provider, of the name, address, and telephone
      number of the independent review entity and of the enrollee's and
      treating health care provider's right to submit additional
      information.
         c.  Notify the selected independent review entity by facsimile
      that the carrier or organized delivery system has chosen it to do the
      independent review and provide sufficient descriptive information to
      identify the type of experts needed to conduct the review.
         d.  Provide to the commissioner by facsimile a copy of the
      notices sent to the enrollee and to the selected independent review
      entity.
         2.  The independent review entity, within three business days of
      receipt of the notice, shall select a person to perform the external
      review and shall provide notice to the enrollee and the carrier
      containing a brief description of the person including the reasons
      the person selected is an expert in the treatment of the medical
      condition under review.  The independent review entity does not need
      to disclose the name of the person.  A copy of the notice shall be
      sent by facsimile to the commissioner.  If the independent review
      entity does not have a person who is an expert in the treatment of
      the medical condition under review and certified by the commissioner
      to conduct an independent review, the independent review entity may
      either decline the review request or may request from the
      commissioner additional time to have such an expert certified.  The
      independent review entity shall notify the commissioner by facsimile
      of its choice between these options within three business days of
      receipt of the notice from the carrier or organized delivery system.
      The commissioner shall provide a notice to the enrollee and carrier
      or organized delivery system of the independent review entity's
      decision and of the commissioner's decision as to how to proceed with
      the external review process within three business days of receipt of
      the independent review entity's decision.
         3.  The enrollee, or the enrollee's treating health care provider
      acting on behalf of the enrollee, may object to the independent
      review entity selected by the carrier or organized delivery system or
      to the person selected as the reviewer by the independent review
      entity by notifying the commissioner and carrier or organized
      delivery system within ten days of the mailing of the notice by the
      independent review entity.  The commissioner shall have two business
      days from receipt of the objection to consider the reasons set forth
      in support of the objection to approve or deny the objection, to
      select an independent review entity if necessary, and to provide
      notice of the commissioner's decision to the enrollee, the enrollee's
      treating health care provider, and the carrier or organized delivery
      system.
         4.  The carrier or organized delivery system, within fifteen days
      of the mailing of the notice by the independent review entity, or
      within three business days of a receipt of notice by the commissioner
      following an objection by the enrollee, whichever is later, shall do
      all of the following:
         a.  Provide to the independent review entity any information
      submitted to the carrier or organized delivery system by the enrollee
      or the enrollee's treating health care provider in support of the
      request for coverage of a service or treatment under the carrier's or
      organized delivery system's appeal procedures.
         b.  Provide to the independent review entity any other
      relevant documents used by the carrier or organized delivery system
      in determining whether the proposed service or treatment should have
      been provided.
         c.  Provide to the commissioner a confirmation that the
      information required in paragraphs "a" and "b" has been
      provided to the independent review entity, including the date the
      information was provided.
         5.  The enrollee, or the enrollee's treating health care provider,
      may provide to the independent review entity any information
      submitted under any internal appeal mechanisms provided under the
      carrier's or organized delivery system's evidence of coverage, and
      other newly discovered relevant information.  The enrollee shall have
      ten business days from the mailing date of the notification of the
      person selected as the reviewer by the independent review entity to
      provide this information.  The independent review entity may
      reasonably decide whether to consider any information provided by the
      enrollee or the enrollee's treating health care provider after the
      ten-day period.
         6.  The independent review entity shall notify the enrollee and
      the enrollee's treating health care provider of any additional
      medical information required to conduct the review within five
      business days of receipt of the documentation required under
      subsection 4.  The enrollee or the enrollee's treating health care
      provider shall provide the requested information to the independent
      review entity within five days after receipt of the notification
      requesting additional medical information.  The independent review
      entity may decide whether it is reasonable to consider any
      information provided by the enrollee or the enrollee's treating
      health care provider after the five-day period.  The independent
      review entity shall notify the commissioner and the carrier or
      organized delivery system of this request.
         7.  The independent review entity shall submit its external review
      decision as soon as possible, but not later than thirty days from the
      date the independent review entity received the information required
      under subsection 4 from the carrier or organized delivery system.
      The independent review entity, for good cause, may request an
      extension of time from the commissioner.  The independent review
      entity's external review decision shall be mailed to the enrollee or
      the treating health care provider acting on behalf of the enrollee,
      the carrier or organized delivery system, and the commissioner.
         8.  The confidentiality of any medical records submitted shall be
      maintained pursuant to applicable state and federal laws.  Other than
      the sharing of information required by this chapter and the rules
      adopted pursuant to this chapter, the commissioner shall keep
      confidential the information obtained in the external review process
      pursuant to section 505.8, subsection 8.
         9.  If an enrollee dies before the completion of the external
      review process, the process shall continue to completion if there is
      potential liability of a carrier or organized delivery system to the
      estate of the enrollee.
         10. a.  If an enrollee who has already received a service or
      treatment under a plan requests external review of the plan's
      coverage decision and changes to another plan before the external
      review process is completed, the carrier or organized delivery system
      whose coverage was in effect at the time the service or treatment was
      received is responsible for completing the external review process.
         b.  If an enrollee who has not yet received service or
      treatment requests external review of a plan's coverage decision and
      then changes to another plan prior to receipt of the service or
      treatment and completion of the external review process, the external
      review process shall begin anew with the enrollee's current carrier
      or organized delivery system.  In this instance, the external review
      process shall be conducted in an expedited manner.  

         99 Acts, ch 41, §13, 22; 2001 Acts, ch 69, §27; 2002 Acts, ch
      1119, §70--72; 2003 Acts, ch 91, §31; 2006 Acts, ch 1117, §65