§ 514g-110

514G.110 Independent review of benefit trigger determinations. 1. Request. An insured may file a written request for independent review of a benefit trigger determination with the commissioner after the internal appeal process has beenexhausted. The request shall be filed within sixty days after the insured receives writtennotice of the insurer’s internal appeal decision. 2. Eligibility for review. The commissioner shall certify that the request is eligible for independent review if all of the following criteria are satisfied: a. The insured was covered by a long-term care insurance policy issued by the insurer at the time the benefit trigger determination was made. b. The sole reason for requesting an independent review is to review the insurer’s determination that the benefit trigger was not met. c. The insured has exhausted all internal appeal procedures provided under the insured’s long-term care insurance policy. d. The written request for independent review was filed by the insured within sixty days from the date of receipt of the insurer’s internal appeal decision. 3. Notice of eligibility.

nsurance policy. d. The written request for independent review was filed by the insured within sixty days from the date of receipt of the insurer’s internal appeal decision. 3. Notice of eligibility. The commissioner shall provide written notice regarding eligibility of a request for independent review to the insured and the insurer within twobusiness days from the date of receipt of the request. a. If the commissioner decides that the request is not eligible for independent review, the written notice shall indicate the reasons for that decision. b. If the commissioner certifies that the request is eligible for independent review, the insurer may appeal that certification by filing a written notice of appeal with the commissionerwithin three business days from the date of receipt of the notice of certification. If uponfurther review, the commissioner upholds the certification, the commissioner shall promptlynotify the insured and the insurer in writing of the reasons for that decision. 4. Qualifications of independent review organizations. The commissioner shall maintain a list of qualified independent review organizations that are certified by the commissioner.Independent review

. 4. Qualifications of independent review organizations. The commissioner shall maintain a list of qualified independent review organizations that are certified by the commissioner.Independent review organizations shall be recertified by the commissioner every two yearsin order to remain on the list. In order to be certified, an independent review organizationshall meet all of the following criteria: a. Have on staff, or contract with, a qualified, licensed health care professional in an appropriate field for determining an insured’s functional or cognitive impairment who canconduct an independent review. (1) In order to be qualified, a licensed health care professional who is a physician shall hold a current certification by a recognized American medical specialty board in a specialtyappropriate for determining an insured’s functional or cognitive impairment. (2) In order to be qualified, a licensed health care professional who is not a physician shall hold a current certification in the specialty in which that person is licensed, by a recognizedAmerican specialty board in a specialty appropriate for determining an insured’s functionalor cognitive impairment. b.

certification in the specialty in which that person is licensed, by a recognizedAmerican specialty board in a specialty appropriate for determining an insured’s functionalor cognitive impairment. b. Ensure that any licensed health care professional who conducts an independent review has no history of disciplinary actions or sanctions, including but not limited to the loss of staffprivileges or any participation restrictions taken or pending by any hospital or state or federalgovernment regulatory agency. c. Ensure that the independent review organization or any of its employees, agents, or licensed health care professionals utilized does not receive compensation of any type that isdependent on the outcome of a review. d. Ensure that the independent review organization or any of its employees, agents, or licensed health care professionals utilized are not in any manner related to, employed by,or affiliated with the insured or with a person who previously provided medical care to theinsured. e. Ensure that an independent review organization or any of its employees, agents, or licensed health care professionals utilized is not a subsidiary of, or owned or controlled by,an insurer or

ured. e. Ensure that an independent review organization or any of its employees, agents, or licensed health care professionals utilized is not a subsidiary of, or owned or controlled by,an insurer or by a trade association of insurers of which the insurer is a member. f. Have a quality assurance program on file with the commissioner that ensures the timeliness and quality of reviews performed, the qualifications and independence of the Sat Dec 23 00:45:47 2023 Iowa Code 2024, Section 514G.110 (21, 0) §514G.110, LONG-TERM CARE INSURANCE ACT 2 licensed health care professionals who perform the reviews, and the confidentiality of thereview process. g. Have on staff or contract with a licensed health care practitioner, as defined in section 514G.103, subsection 3, who is qualified to certify that an individual is chronically ill forpurposes of a qualified long-term care insurance contract. 5. Independent review process. The independent review process shall be conducted as follows: a. Within three business days of receiving a notice from the commissioner of the certification of a request for independent review or receipt of a denial of an insurer’s appealfrom such a certification, the

in three business days of receiving a notice from the commissioner of the certification of a request for independent review or receipt of a denial of an insurer’s appealfrom such a certification, the insurer shall do all of the following: (1) Select an independent review organization from the list certified by the commissioner and notify the insured in writing of the name, address, and telephone number of the selectedindependent review organization. The selected independent review organization shall utilizea licensed health care professional with qualifications appropriate to the benefit triggerdetermination that is under review. (2) Notify the independent review organization that it has been selected to conduct an independent review of a benefit trigger determination and provide sufficient descriptiveinformation to enable the independent review organization to provide licensed health careprofessionals who will be qualified to conduct the review. (3) Provide the commissioner with a copy of the notices sent to the insured and to the selected independent review organization. b. Within three business days of receiving a notice from an insurer that it has been selected to conduct an

opy of the notices sent to the insured and to the selected independent review organization. b. Within three business days of receiving a notice from an insurer that it has been selected to conduct an independent review, the independent review organization shall do one of thefollowing: (1) Accept its selection as the independent review organization, designate a qualified licensed health care professional to perform the independent review, and provide notice ofthat designation to the insured and the insurer, including a brief description of the healthcare professional’s qualifications and the reasons that person is qualified to determinewhether the insured’s benefit trigger has been met. A copy of this notice shall be sent to thecommissioner via facsimile. The independent review organization is not required to disclosethe name of the health care professional selected. (2) Decline its selection as the independent review organization or, if the independent review organization does not have a licensed health care professional who is qualified toconduct the independent review available, request additional time from the commissioner tohave a qualified licensed health care professional

ave a licensed health care professional who is qualified toconduct the independent review available, request additional time from the commissioner tohave a qualified licensed health care professional certified, and provide notice to the insured,the insurer, and the commissioner. The commissioner shall notify the independent revieworganization, the insured, and the insurer of how to proceed within three business days ofreceipt of such notice from the independent review organization. c. An insured may object to the independent review organization selected by the insurer or to the licensed health care professional designated by the independent review organizationto conduct the review by filing a notice of objection along with reasons for the objection,with the commissioner within ten days of receipt of a notice sent by the independent revieworganization pursuant to paragraph 'b'. The commissioner shall consider the insured’sobjection and shall notify the insured, the insurer, and the independent review organizationof the commissioner’s decision to sustain or deny the objection within two business days ofreceipt of the objection. d.

d shall notify the insured, the insurer, and the independent review organizationof the commissioner’s decision to sustain or deny the objection within two business days ofreceipt of the objection. d. Within five business days of receiving a notice from the independent review organization accepting its selection or within five business days of receiving a denial of anobjection to the independent review organization selected, whichever is later, the insuredmay submit any information or documentation in support of the insured’s claim to both theindependent review organization and the insurer. e. Within fifteen days of receiving a notice from the independent review organization accepting its selection or within three business days of receipt of a denial of an objectionto the independent review organization selected, whichever is later, an insurer shall do all ofthe following: (1) Provide the independent review organization with any information submitted to the Sat Dec 23 00:45:47 2023 Iowa Code 2024, Section 514G.110 (21, 0) insurer by the insured in support of the insured’s internal appeal of the insurer’s benefittrigger determination.

on submitted to the Sat Dec 23 00:45:47 2023 Iowa Code 2024, Section 514G.110 (21, 0) insurer by the insured in support of the insured’s internal appeal of the insurer’s benefittrigger determination. (2) Provide the independent review organization with any other relevant documents used by the insurer in making its benefit trigger determination. (3) Provide the insured and the commissioner with confirmation that the information required under subparagraphs (1) and (2) has been provided to the independent revieworganization, including the date the information was provided. f. The independent review organization shall not commence its review until fifteen days after the selection of the independent review organization is final including the resolutionof any objection made pursuant to paragraph 'c'. During this time period, the insurer mayconsider any information provided by the insured pursuant to paragraph 'd' and overturn oraffirm the insurer’s benefit trigger determination based on such information. If the insureroverturns its benefit trigger determination, the independent review process shall immediatelycease. g.

rn oraffirm the insurer’s benefit trigger determination based on such information. If the insureroverturns its benefit trigger determination, the independent review process shall immediatelycease. g. In conducting a review, the independent review organization shall consider only the information and documentation provided to the independent review organization pursuantto paragraphs 'd' and 'e'. h. The independent review organization shall submit its decision as soon as possible, but not later than thirty days from the date the independent review organization receives theinformation required under paragraphs 'd' and 'e', whichever is received later. The decisionshall include a description of the basis for the decision and the date of the benefit triggerdetermination to which the decision relates. The independent review organization, for goodcause, may request an extension of time from the commissioner to file its decision. A copy ofthe decision shall be mailed to the insured, the insurer, and the commissioner. i. All medical records submitted for use by the independent review organization shall be maintained as confidential records as required by applicable state and federal laws.

er, and the commissioner. i. All medical records submitted for use by the independent review organization shall be maintained as confidential records as required by applicable state and federal laws. Thecommissioner shall keep all information obtained during the independent review processconfidential pursuant to section 505.8, subsection 8, except that the commissioner may sharesome information obtained as provided under section 505.8, subsection 8, and as required bythis chapter and rules adopted pursuant to this chapter. j. If an insured dies before completion of the independent review, the review shall continue to completion if there is potential liability of an insurer to the estate of the insured or to aprovider for rendering qualified long-term care services to the insured. 6. Costs. All reasonable fees and costs of the independent review organization in conducting an independent review under this section shall be paid by the insurer. 7. Immunity. An independent review organization that conducts a review under this section is not liable for damages arising from determinations made during the review.Immunity does not apply to any act or omission made by an independent review

ion that conducts a review under this section is not liable for damages arising from determinations made during the review.Immunity does not apply to any act or omission made by an independent review organizationin bad faith or that involves gross negligence. 8. Effect of independent review decision.a. The review decision by the independent review organization conducting the review is binding on the insurer. b. The independent review process set forth in this section shall not be considered a contested case under chapter 17A. c. An insured may appeal the review decision by the independent review organization conducting the review by filing a petition for judicial review in the district court in thecounty in which the insured resides. The petition for judicial review shall be filed withinfifteen business days after the issuance of the review decision by the independent revieworganization. The petition shall name the insured as the petitioner and the insurer as therespondent. The petitioner shall not name the independent review organization as a party.The commissioner shall not be named as a respondent unless the insured alleges actionor inaction by the commissioner under the

petitioner shall not name the independent review organization as a party.The commissioner shall not be named as a respondent unless the insured alleges actionor inaction by the commissioner under the standards articulated under section 17A.19,subsection 10. Allegations made against the commissioner under section 17A.19, subsection10, must be stated with particularity. The commissioner may, upon motion, intervene ina judicial review proceeding brought pursuant to this paragraph. The findings of fact by Sat Dec 23 00:45:47 2023 Iowa Code 2024, Section 514G.110 (21, 0) §514G.110, LONG-TERM CARE INSURANCE ACT 4 the independent review organization conducting the review are conclusive and binding onappeal. d. An insurer shall not be subject to any penalties, sanctions, or damages for complying in good faith with a review decision rendered by an independent review organization pursuantto this section. e. Nothing contained in this section or in section 514G.109 shall be construed to limit the right of an insurer to assert any rights an insurer may have under a long-term care insurancepolicy related to: (1) An insured’s misrepresentation.(2) Changes in the insured’s benefit eligibility.(3)

right of an insurer to assert any rights an insurer may have under a long-term care insurancepolicy related to: (1) An insured’s misrepresentation.(2) Changes in the insured’s benefit eligibility.(3) Terms, conditions, and exclusions contained in the policy, other than failure to meet the benefit trigger. f. The requirements of this section and section 514G.109 are not applicable to a group long-term care insurance policy that is governed by the federal Employee Retirement IncomeSecurity Act of 1974, as codified at 29 U.S.C. §1001 et seq. g. The provisions of this section and section 514G.109 are in lieu of and supersede any other third-party review requirement contained in chapter 514J or in any other provision oflaw. h. The insured may bring an action in the district court in the county in which the insured resides to enforce the review decision of the independent review organization conducting thereview or the decision of the court on appeal. 9. Receipt of notice. Notice required by this section shall be deemed received within five days after the date of mailing. 2008 Acts, ch 1175, §11, 18; 2011 Acts, ch 34, §118; 2017 Acts, ch 105, §1; 2021 Acts, ch 181, §14 Referred to in

by this section shall be deemed received within five days after the date of mailing. 2008 Acts, ch 1175, §11, 18; 2011 Acts, ch 34, §118; 2017 Acts, ch 105, §1; 2021 Acts, ch 181, §14 Referred to in §514G.103, 514G.109 Sat Dec 23 00:45:47 2023 Iowa Code 2024, Section 514G.110 (21, 0)