514F.8 Prior authorizations — reimbursement. 1. For purposes of this section:a. 'Covered person' means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan. b. 'Facility' means the same as defined in section 514J.102.c. 'Health benefit plan' means the same as defined in section 514J.102.d. 'Health care professional' means the same as defined in section 514J.102.e. 'Health care provider' means a health care professional or a facility.f. 'Health care services' means services provided by a health care provider for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, ordisease. 'Health care services' includes the provision of durable medical equipment. 'Healthcare services' does not include prescription drugs or dental care services as that term isdefined in section 514J.102. g. 'Health carrier' means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance companyoffering sickness and accident plans, a health maintenance organization, a nonprofit healthservice corporation, a plan established pursuant to chapter the commissioner, including an insurance companyoffering sickness and accident plans, a health maintenance organization, a nonprofit healthservice corporation, a plan established pursuant to chapter 509A for public employees, orany other entity providing a plan of health insurance, health care benefits, or health careservices. 'Health carrier' does not include the department of health and human services,or a managed care organization acting pursuant to a contract with the department of healthand human services to administer the medical assistance program under chapter 249A or thehealthy and well kids in Iowa (Hawki) program under chapter 514I. h. 'Prior authorization' means a determination by a utilization review organization that a specific health care service proposed by a health care provider for a covered person ismedically necessary or medically appropriate, and the determination is made prior to theprovision of the health care service to the covered person, and, if applicable, includes autilization review organization’s requirement that a covered person or a health care providernotify the utilization review organization prior to receiving or providing a specific healthcare includes autilization review organization’s requirement that a covered person or a health care providernotify the utilization review organization prior to receiving or providing a specific healthcare service. i. 'Utilization review' means the same as defined in section 514F.4, subsection 3.j. 'Utilization review organization' means an entity that performs utilization review, including a health carrier that meets the requirements established for accreditation setby the utilization review accreditation commission or the national committee on qualityassurance and that performs utilization review for the health carrier’s health benefit plans. 2. a. A utilization review organization shall not revoke, or impose a limitation, condition, or restriction on, a prior authorization after the date on which a health care provider providesa health care service to a covered person per the prior authorization. b. A health carrier shall reimburse a health care provider at the contracted reimbursement rate for a health care service provided by the health care provider to a covered person per aprior authorization. c. lth carrier shall reimburse a health care provider at the contracted reimbursement rate for a health care service provided by the health care provider to a covered person per aprior authorization. c. Paragraphs 'a' and 'b' shall not apply in any of the following circumstances:(1) The health care provider or the covered person committed fraud, waste, or abuse.(2) The health care provider or the covered person provided inaccurate information that the utilization review organization relied on for the utilization review organization’s priorauthorization determination. (3) On the date that the health care service was provided by the health care provider to the covered person per the prior authorization, the health care service was no longer a benefitcovered by the covered person’s health benefit plan. (4) On the date that the health care service was provided by the health care provider to the covered person per the prior authorization, the health care provider was no longer contractedwith the health carrier that provides the covered person’s health benefit plan. (5) The health care provider failed to meet the health carrier’s requirements related to timely filing of claims for tedwith the health carrier that provides the covered person’s health benefit plan. (5) The health care provider failed to meet the health carrier’s requirements related to timely filing of claims for submission of a claim for the health care service provided by thehealth care provider to the covered person per the prior authorization. (6) Due to coordination of benefits, the health carrier does not have liability for a claim Sat Dec 23 00:45:36 2023 Iowa Code 2024, Section 514F.8 (4, 3) §514F.8, UTILIZATION AND COST CONTROL 2 for the health care service provided by the health care provider to the covered person per aprior authorization. (7) On the date that the health care service was provided by the health care provider to the covered person per the prior authorization, the covered person was no longer a participantin the health benefit plan in which the covered person participated on the date that the priorauthorization was received by the health care provider. 3. A prior authorization for a specific health care service for a covered person shall be valid for the specific health care service for not less than ninety days from the date that thecovered person’s health care horization for a specific health care service for a covered person shall be valid for the specific health care service for not less than ninety days from the date that thecovered person’s health care provider receives the prior authorization from a utilizationreview organization, provided that during the ninety days the covered person remains aparticipant in the same health benefit plan in which the covered person participated on thedate the prior authorization was received by the health care provider. 4. The commissioner may adopt rules pursuant to chapter 17A as necessary to administer this chapter. 2022 Acts, ch 1056, §1, 2; 2023 Acts, ch 19, §1204Section applies January 1, 2023, to health benefit plans that are delivered, issued for delivery, continued, or renewed in this state on or after that date; 2022 Acts, ch 1056, §2 Subsection 1, paragraph g amended Sat Dec 23 00:45:36 2023 Iowa Code 2024, Section 514F.8 (4, 3)
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