514J.104 Notice of right to external review. 1. A health carrier shall notify a covered person or the covered person’s authorized representative, if known, in writing of the covered person’s right to request an externalreview and include the appropriate statements and information set forth in this chapter atthe time the health carrier sends written notice of a final adverse determination. 2. a. The notice shall include the following, or substantially equivalent, language: We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right tohave our decision reviewed by health care professionals who haveno association with us if our decision involved making a judgmentas to the medical necessity, appropriateness, health care setting,level of care, or effectiveness of the health care service or treatmentyou requested by submitting a request for external review to thecommissioner of insurance. b. The notice shall include the current address and contact information for the commissioner as specified in administrative rule. 3. ing a request for external review to thecommissioner of insurance. b. The notice shall include the current address and contact information for the commissioner as specified in administrative rule. 3. The health carrier shall include in the notice a statement informing the covered person or the covered person’s authorized representative, if known, of the following: a. If the covered person has a medical condition pursuant to which the time frame for completion of a standard external review would seriously jeopardize the life or health of thecovered person or would jeopardize the covered person’s ability to regain maximum function,the covered person or the covered person’s authorized representative may file a request foran expedited external review. b. If the final adverse determination concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services, but hasnot been discharged from a facility, the covered person or the covered person’s authorizedrepresentative may request an expedited external review. c. If the final adverse determination concerns a denial of coverage based on a determination that the person or the covered person’s authorizedrepresentative may request an expedited external review. c. If the final adverse determination concerns a denial of coverage based on a determination that the recommended or requested health care service or treatment isexperimental or investigational as provided in section 514J.109, the covered person mayfile a request for external review pursuant to section 514J.109. In addition, if the coveredperson’s treating health care professional certifies in writing that the recommended orrequested health care service or treatment that is the subject of the recommendation orrequest would be significantly less effective if not promptly initiated, the covered person orthe covered person’s authorized representative may request an expedited external reviewpursuant to section 514J.109, subsection 18. 4. The health carrier shall include with the notice a copy of the descriptions of both the standard and expedited external review procedures the health carrier is required toprovide pursuant to section 514J.116, highlighting the provisions in the external reviewprocedures that give the covered person or the covered person’s authorized representativethe rier is required toprovide pursuant to section 514J.116, highlighting the provisions in the external reviewprocedures that give the covered person or the covered person’s authorized representativethe opportunity to submit additional information and including any forms used to processan external review. 5. The health carrier shall also include with the notice an authorization form, or other document approved by the commissioner that complies with the requirements of 45 C.F.R.§164.508 and with Tit. I of the federal Genetic Information Nondiscrimination Act of 2008,Pub. L. No. 110-233, 122 Stat. 881, by which the covered person or the covered person’sauthorized representative authorizes the health carrier and the covered person’s treatinghealth care provider to disclose protected health information, including medical records,concerning the covered person that is pertinent to the external review. 2011 Acts, ch 101, §4 Sat Dec 23 00:46:12 2023 Iowa Code 2024, Section 514J.104 (16, 0)
Iowa Legal Code