514J.108 External review — expedited. 1. Notwithstanding section 514J.107, a covered person or the covered person’s authorized representative may make an oral or written request to the commissioner for anexpedited external review at the time the covered person or the covered person’s authorizedrepresentative receives any of the following: a. An adverse determination that involves a medical condition of the covered person for which the time frame for completion of an internal review of a grievance involving an adversedetermination would seriously jeopardize the life or health of the covered person or wouldjeopardize the covered person’s ability to regain maximum function. b. A final adverse determination that involves a medical condition where the time frame for completion of a standard external review would seriously jeopardize the life or healthof the covered person or would jeopardize the covered person’s ability to regain maximumfunction. c. A final adverse determination that concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergencyservices, and the covered person has not been discharged from a facility. rns an admission, availability of care, continued stay, or health care service for which the covered person received emergencyservices, and the covered person has not been discharged from a facility. 2. a. Upon receipt of a request for an expedited external review, the commissioner shall immediately send written notice of the request to the health carrier. b. Immediately upon receipt of notice of a request for expedited external review, the health carrier shall complete a preliminary review of the request to determine whether the requestmeets the eligibility requirements for external review set forth in section 514J.107, subsection3, and this section. c. The health carrier shall then immediately issue a notice of initial determination informing the commissioner and the covered person or the covered person’s authorizedrepresentative of its eligibility determination including a statement informing the coveredperson or the covered person’s authorized representative of the right to appeal thatdetermination to the commissioner. d. The commissioner may specify by rule the form required for the health carrier’s notice of initial determination and any supporting information to be included thatdetermination to the commissioner. d. The commissioner may specify by rule the form required for the health carrier’s notice of initial determination and any supporting information to be included in the notice. 3. The commissioner may determine that a request is eligible for expedited external review, notwithstanding a health carrier’s initial determination that the request is not eligible.In making a determination, the commissioner’s decision shall be made in accordance withthe terms of the covered person’s health benefit plan and shall be subject to all applicableprovisions of this chapter. The commissioner shall make a determination pursuant to thissubsection as expeditiously as possible. 4. a. Upon receipt of notice from a health carrier that a request is eligible for expedited external review or upon a determination by the commissioner that a request is eligiblefor expedited external review, the commissioner shall immediately assign an independentreview organization from the list of approved independent review organizations maintainedby the commissioner to conduct the expedited external review. missioner shall immediately assign an independentreview organization from the list of approved independent review organizations maintainedby the commissioner to conduct the expedited external review. The commissioner shallthen immediately notify the health carrier and the covered person or the covered person’sauthorized representative of the name of the assigned independent review organization. b. The assignment of an independent review organization shall be done on a random basis among those approved independent review organizations qualified to conduct the particularexternal review based on the nature of the health care service that is the subject of the adversedetermination or final adverse determination and other circumstances, including conflict ofinterest concerns. 5. Upon receiving notice of the independent review organization assigned to conduct the expedited external review, the health carrier shall provide or transmit all necessarydocuments and information considered in making the adverse determination or final adversedetermination to the independent review organization electronically or by telephone orfacsimile or any other available expeditious method. 6. dered in making the adverse determination or final adversedetermination to the independent review organization electronically or by telephone orfacsimile or any other available expeditious method. 6. The independent review organization is not bound by any decisions or conclusions reached during the health carrier’s internal grievance process. The independent revieworganization shall consider the documents and information provided by the health carrier, Sat Dec 23 00:46:14 2023 Iowa Code 2024, Section 514J.108 (16, 0) §514J.108, EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS 2 and to the extent the information or documents are available and the independent revieworganization considers them appropriate, shall consider the following in reaching a decision: a. The covered person’s pertinent medical records.b. The treating health care professional’s recommendation.c. Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person or the covered person’s authorizedrepresentative, or the covered person’s treating physician or other health care professional. d. and other documents submitted by the health carrier, covered person or the covered person’s authorizedrepresentative, or the covered person’s treating physician or other health care professional. d. The terms of coverage under the covered person’s health benefit plan with the health carrier, to ensure that the independent review organization’s decision is not contrary to theterms of coverage under the covered person’s health benefit plan with the health carrier. e. The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by thefederal government, national or professional medical societies, boards, and associations. f. Any applicable clinical review criteria developed and used by the health carrier. g. The opinion of the independent review organization’s clinical reviewer after considering the information or documents described in paragraphs 'a' through 'f' to theextent the information or documents are available and the clinical reviewer considers themrelevant. 7. a. As expeditiously as the covered person’s medical condition or circumstances require, but in no event more than ation or documents are available and the clinical reviewer considers themrelevant. 7. a. As expeditiously as the covered person’s medical condition or circumstances require, but in no event more than seventy-two hours after the date of receipt of an eligible requestfor expedited external review, the assigned independent review organization shall do all ofthe following: (1) Make a decision to uphold or reverse the adverse determination or final adverse determination of the health carrier. (2) Notify the covered person or the covered person’s authorized representative, the health carrier, and the commissioner of its decision. b. If the notice given by the independent review organization pursuant to paragraph 'a' was not in writing, within forty-eight hours after providing that notice, the independentreview organization shall provide written confirmation of the decision to the covered personor the covered person’s authorized representative, the health carrier, and the commissionerthat includes the information set forth in section 514J.107, subsection 13, paragraph 'b'. c. Upon receipt of the notice of decision by an independent review organization pursuant to paragraph 'a' reversing cludes the information set forth in section 514J.107, subsection 13, paragraph 'b'. c. Upon receipt of the notice of decision by an independent review organization pursuant to paragraph 'a' reversing the adverse determination or final adverse determination, thehealth carrier shall immediately approve the coverage that was the subject of the adversedetermination or final adverse determination. 2011 Acts, ch 101, §8; 2012 Acts, ch 1021, §99Referred to in §514J.106, 514J.109 Sat Dec 23 00:46:14 2023 Iowa Code 2024, Section 514J.108 (16, 0)
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