Bill Text: IA HF597 | 2011-2012 | 84th General Assembly | Enrolled

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: A bill for an act creating new procedures for external review of health care coverage decisions by health carriers and including transition and applicability provisions. (Formerly HSB 200) Effective 7-01-11.

Spectrum: Committee Bill

Status: (Passed) 2011-12-31 - END OF 2011 ACTIONS [HF597 Detail]

Download: Iowa-2011-HF597-Enrolled.html

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House File 597
AN ACT
CREATING NEW PROCEDURES FOR EXTERNAL REVIEW OF HEALTH CARE
COVERAGE DECISIONS BY HEALTH CARRIERS AND INCLUDING
TRANSITION AND APPLICABILITY PROVISIONS.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
Section 1. NEW SECTION . 514J.101 Purpose —— applicability.
The purpose of this chapter is to provide uniform standards
for the establishment and maintenance of external review
procedures to assure that covered persons have the opportunity
for an independent review of an adverse determination or final
adverse determination made by a health carrier as required
by the federal Patient Protection and Affordable Care Act,
Pub. L. No. 111-148, as amended by the federal Health Care and
Education Reconciliation Act of 2010, Pub. L. No. 111-152,
which amends the Public Health Service Act and adopts, in part,
new 42 U.S.C. § 300gg-19, and to address issues which are
unique to the external review process in this state.
Sec. 2. NEW SECTION . 514J.102 Definitions.
As used in this chapter, unless the context otherwise
requires:
1. “Adverse determination” means a determination by a health
carrier that an admission, availability of care, continued
stay, or other health care service that is a covered benefit
has been reviewed and, based upon the information provided,
does not meet the health carrier’s requirements for medical
necessity, appropriateness, health care setting, level of care,
or effectiveness, and the requested service or payment for the
service is therefore denied, reduced, or terminated. “Adverse
determination” does not include a denial of coverage for a
service or treatment specifically listed in plan or evidence of

House File 597, p. 2
coverage documents as excluded from coverage.
2. “Authorized representative” means any of the following:
a. A person to whom a covered person has given express
written consent to represent the covered person in an external
review.
b. A person authorized by law to provide substituted consent
for a covered person.
c. A family member of the covered person when the covered
person is unable to provide consent.
d. The covered person’s treating health care professional
when the covered person is unable to provide consent.
3. “Best evidence” means evidence based on randomized
clinical trials. If randomized clinical trials are not
available, “best evidence” means evidence based on cohort
studies or case-control studies. If randomized clinical
trials, cohort studies, or case-control studies are not
available, “best evidence” means evidence based on case-series
studies. If none of these are available, “best evidence” means
evidence based on expert opinion.
4. “Case-control study” means a retrospective evaluation
of two groups of patients with different outcomes to determine
which specific interventions the patients received.
5. “Case-series study” means an evaluation of a series
of patients with a particular outcome, without the use of a
control group.
6. “Certification” means a determination by a health carrier
that an admission, availability of care, continued stay, or
other health care service has been reviewed and, based on
the information provided, satisfies the health carrier’s
requirements for medical necessity, appropriateness, health
care setting, level of care, and effectiveness.
7. “Clinical review criteria” means the written screening
procedures, decision abstracts, clinical protocols, and
practice guidelines used by a health carrier to determine the
necessity and appropriateness of health care services.
8. “Cohort study” means a prospective evaluation of two
groups of patients with only one group of patients receiving a
specific intervention.
9. “Commissioner” means the commissioner of insurance.
10. “Covered benefits” or “benefits” means those health care
services to which a covered person is entitled under the terms
of a health benefit plan.
11. “Covered person” means a policyholder, subscriber,

House File 597, p. 3
enrollee, or other individual participating in a health benefit
plan.
12. “Disclose” means to release, transfer, or otherwise
divulge protected health information to any person other than
the individual who is the subject of the protected health
information.
13. “Emergency medical condition” means the sudden and, at
the time, unexpected onset of a health condition or illness
that requires immediate medical attention, where failure to
provide medical attention would result in a serious impairment
to bodily functions, serious dysfunction of a bodily organ or
part, or would place the person’s health in serious jeopardy.
14. “Emergency services” means health care items and
services furnished or required to evaluate and treat an
emergency medical condition.
15. “Evidence-based standard” means the conscientious,
explicit, and judicious use of the current best evidence based
on the overall systematic review of the research in making
decisions about the care of individual patients.
16. “Expert opinion” means a belief or an interpretation
by specialists with experience in a specific area about
the scientific evidence pertaining to a particular service,
intervention, or therapy.
17. “Facility” means an institution providing health
care services or a health care setting, including but not
limited to hospitals and other licensed inpatient centers,
ambulatory surgical or treatment centers, skilled nursing
centers, residential treatment centers, diagnostic, laboratory
and imaging centers, and rehabilitation and other therapeutic
health settings.
18. “Final adverse determination” means an adverse
determination involving a covered benefit that has been upheld
by a health carrier at the completion of the health carrier’s
internal grievance process.
19. “Health benefit plan” means a policy, contract,
certificate, or agreement offered or issued by a health carrier
to provide, deliver, arrange for, pay for, or reimburse any of
the costs of health care services.
20. “Health care professional” means a physician or other
health care practitioner licensed, accredited, registered, or
certified to perform specified health care services consistent
with state law.
21. “Health care provider” or “provider” means a health care

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professional or a facility.
22. “Health care services” means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition,
illness, injury, or disease.
23. “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 company offering sickness and accident plans, a
health maintenance organization, a nonprofit health service
corporation, a plan established pursuant to chapter 509A
for public employees, or any other entity providing a plan
of health insurance, health care benefits, or health care
services. “Health carrier” includes, for purposes of this
chapter, an organized delivery system.
24. “Health information” means information or data, whether
oral or recorded in any form or medium, and personal facts or
information about events or relationships that relates to any
of the following:
a. The past, present, or future physical, mental, or
behavioral health or condition of a covered person or a member
of the covered person’s family.
b. The provision of health care services to a covered
person.
c. Payment to a health care provider for the provision of
health care services to a covered person.
25. “Independent review organization” means an entity that
conducts independent external reviews of adverse determinations
and final adverse determinations.
26. “Medical or scientific evidence” means evidence found in
any of the following sources:
a. Peer-reviewed scientific studies published in or accepted
for publication by medical journals that meet nationally
recognized requirements for scientific manuscripts and that
submit most of their published articles for review by experts
who are not part of the editorial staff.
b. Peer-reviewed medical literature, including literature
relating to therapies reviewed and approved by a qualified
institutional review board, biomedical compendia, and other
medical literature that meet the criteria of the national
institutes of health’s national library of medicine for
indexing in index medicus or medline, or of elsevier science
ltd. for indexing in excerpta medicus or embase.
c. Medical journals recognized by the United States

House File 597, p. 5
secretary of health and human services under section 1861(t)(2)
of the federal Social Security Act.
d. The following standard reference compendia:
(1) American hospital formulary service drug information.
(2) Drug facts and comparisons.
(3) American dental association accepted dental
therapeutics.
(4) United States pharmacopoeia drug information.
e. Findings, studies, or research conducted by or under
the auspices of federal government agencies and nationally
recognized federal research institutes, including any of the
following:
(1) Federal agency for health care research and quality.
(2) National institutes of health.
(3) National cancer institute.
(4) National academy of sciences.
(5) Centers for Medicare and Medicaid services.
(6) Federal food and drug administration.
(7) Any national board recognized by the national
institutes of health for the purpose of evaluating the medical
value of health care services.
f. Any other medical or scientific evidence that is
comparable to the sources listed in paragraphs “a” through “e” .
27. “NAIC” means the national association of insurance
commissioners.
28. “Organized delivery system” means an entity system
authorized under 1993 Iowa Acts, ch. 158, and licensed by the
director of public health, and performing utilization review.
29. “Person” means an individual, a corporation, a
partnership, an association, a joint venture, a joint stock
company, a trust, an unincorporated organization, any similar
entity, or any combination of the foregoing.
30. “Protected health information” means health information
that meets either of the following descriptions:
a. Health information that identifies a covered person who
is the subject of the information.
b. Health information with respect to which there is a
reasonable basis to believe that the information could be used
to identify a covered person.
31. “Randomized clinical trial” means a controlled,
prospective study of patients that have been randomized into an
experimental group and a control group at the beginning of the
study with only the experimental group of patients receiving a

House File 597, p. 6
specific intervention, which includes study of the groups for
variables and anticipated outcomes over time.
Sec. 3. NEW SECTION . 514J.103 Applicability and scope.
1. Except as provided in subsection 2, this chapter shall
apply to all health carriers.
2. This chapter shall not apply to any of the following:
a. A policy or certificate that provides coverage only for a
specified disease, specified accident or accident-only, credit,
disability income, hospital indemnity, long-term care, dental
care, vision care, or any other limited supplemental benefit.
b. A Medicare supplement policy of insurance, as defined by
the commissioner by rule.
c. Coverage under a plan through Medicare, Medicaid, or the
federal employees health benefits program, any coverage issued
under 10 U.S.C. ch. 55, and any coverage issued as supplemental
to that coverage.
d. Any coverage issued as supplemental to liability
insurance.
e. Workers’ compensation or similar insurance.
f. Automobile medical-payment insurance or any insurance
under which benefits are payable with or without regard to
fault, whether written on a group blanket or individual basis.
Sec. 4. NEW SECTION . 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 external
review and include the appropriate statements and information
set forth in this chapter at the 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 to have our decision reviewed by health care
professionals who have no association with us if our decision
involved making a judgment as to the medical necessity,
appropriateness, health care setting, level of care, or
effectiveness of the health care service or treatment you
requested by submitting a request for external review to the
commissioner of insurance.
b. The notice shall include the current address and contact
information for the commissioner as specified in administrative

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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 the
covered 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 for an
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
has not been discharged from a facility, the covered person or
the covered person’s authorized representative 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 is experimental
or investigational as provided in section 514J.109, the
covered person may file a request for external review pursuant
to section 514J.109. In addition, if the covered person’s
treating health care professional certifies in writing that
the recommended or requested health care service or treatment
that is the subject of the recommendation or request would
be significantly less effective if not promptly initiated,
the covered person or the covered person’s authorized
representative may request an expedited external review
pursuant 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 to provide
pursuant to section 514J.116, highlighting the provisions in
the external review procedures that give the covered person or
the covered person’s authorized representative the opportunity
to submit additional information and including any forms used
to process an 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.

House File 597, p. 8
881, by which the covered person or the covered person’s
authorized representative authorizes the health carrier and
the covered person’s treating health care provider to disclose
protected health information, including medical records,
concerning the covered person that is pertinent to the external
review.
Sec. 5. NEW SECTION . 514J.105 Request for external review.
A covered person or the covered person’s authorized
representative may make a request for an external review of
a final adverse determination. Except for a request for an
expedited external review, all requests for external review
shall be made in writing to the commissioner. The commissioner
may prescribe by rule the form and content of external review
requests.
Sec. 6. NEW SECTION . 514J.106 Exhaustion of internal
grievance process —— exceptions —— expedited external review
request.
1. Except as otherwise provided in this section, a request
for an external review shall not be made until the covered
person or the covered person’s authorized representative has
exhausted the health carrier’s internal grievance process and
received a final adverse determination.
2. A covered person or the covered person’s authorized
representative shall be considered to have exhausted the health
carrier’s internal grievance process if the covered person or
the covered person’s authorized representative has filed a
grievance involving an adverse determination and, except to the
extent the covered person or the covered person’s authorized
representative requested or agreed to a delay, has not received
a written decision on the grievance from the health carrier
within thirty days following the date the covered person or the
covered person’s authorized representative filed the grievance
with the health carrier.
3. A covered person or the covered person’s authorized
representative may file a request for an expedited external
review of an adverse determination without exhausting the
health carrier’s internal grievance process under either of the
following circumstances:
a. The covered person has a medical condition pursuant
to which the time frame for completion of an internal review
of the grievance involving an adverse determination would
seriously jeopardize the life or health of the covered person
or would jeopardize the covered person’s ability to regain

House File 597, p. 9
maximum function as provided in section 514J.108.
b. The adverse determination involves a denial of
coverage based on a determination that the recommended or
requested health care service or treatment is experimental or
investigational and the covered person’s treating physician
certifies in writing that the recommended or requested health
care service or treatment that is the subject of the adverse
determination would be significantly less effective if not
promptly initiated as provided in section 514J.109.
4. A request for an external review of an adverse
determination may be made before the covered person or the
covered person’s authorized representative has exhausted the
health carrier’s internal grievance procedures whenever the
health carrier agrees to waive the exhaustion requirement.
If the requirement to exhaust the health carrier’s internal
grievance procedures is waived, the covered person or the
covered person’s authorized representative may file a request
with the commissioner in writing for a standard external
review.
Sec. 7. NEW SECTION . 514J.107 External review —— standard.
1. A covered person or the covered person’s authorized
representative may file a written request for an external
review with the commissioner within four months after any of
the following events:
a. The date of receipt of a final adverse determination.
b. The failure of a health carrier to issue a written
decision within thirty days following the date the covered
person or the covered person’s authorized representative filed
a grievance involving an adverse determination as provided in
section 514J.106, subsection 2.
c. The agreement of the health carrier to waive the
requirement that the covered person or the covered person’s
authorized representative exhaust the health carrier’s internal
grievance procedures before filing a request for external
review of an adverse determination as provided in section
514J.106, subsection 4.
2. Within one business day after the date of receipt of a
request for external review, the commissioner shall send a copy
of the request to the health carrier.
3. Within five business days following the date of receipt
of the external review request from the commissioner, the
health carrier shall complete a preliminary review of the
request to determine whether:

House File 597, p. 10
a. The individual is or was a covered person under the
health benefit plan at the time the health care service was
recommended or requested.
b. The health care service that is the subject of the
adverse determination or of the final adverse determination,
is a covered service under the covered person’s health benefit
plan, but for a determination by the health carrier that the
health care service is not covered because it does not meet
the health carrier’s requirements for medical necessity,
appropriateness, health care setting, level of care, or
effectiveness.
c. The covered person or the covered person’s authorized
representative has exhausted the health carrier’s internal
grievance process, unless the covered person or the covered
person’s authorized representative is not required to exhaust
the health carrier’s internal grievance process pursuant to
section 514J.106 or this section.
d. The covered person or the covered person’s authorized
representative has provided all the information and forms
required to process an external review request.
4. Within one business day after completion of a preliminary
review pursuant to subsection 3, the health carrier shall
notify the commissioner and the covered person or the covered
person’s authorized representative in writing whether the
request is complete and whether the request is eligible for
external review.
a. If the health carrier determines that the request is not
complete, the health carrier shall notify the covered person
or the covered person’s authorized representative and the
commissioner in writing that the request is not complete and
what information or materials are needed to make the request
complete.
b. If the health carrier determines that the request
is not eligible for external review, the health carrier
shall issue a notice of initial determination in writing
informing the covered person or the covered person’s authorized
representative and the commissioner of that determination
and the reasons the request is not eligible for review. The
health carrier shall also include a statement in the notice
informing the covered person or the covered person’s authorized
representative that the health carrier’s initial determination
of ineligibility may be appealed to the commissioner.
5. The commissioner may specify by rule the form required

House File 597, p. 11
for the health carrier’s notice of initial determination and
any supporting information to be included in the notice.
6. The commissioner may determine that a request is eligible
for external review, notwithstanding a health carrier’s initial
determination that the request is not eligible, and refer the
request for external review. In making this determination, the
commissioner’s decision shall be made in accordance with the
terms of the covered person’s health benefit plan and shall be
subject to all applicable provisions of this chapter.
7. Within one business day after receipt of notice from
a health carrier that a request for external review is
eligible for external review or upon a determination by the
commissioner that a request is eligible for external review,
the commissioner shall do all of the following:
a. Assign an independent review organization from the list
of approved independent review organizations maintained by the
commissioner and notify the health carrier of the name of the
assigned independent review organization. The assignment of
an independent review organization shall be done on a random
basis among those approved independent review organizations
qualified to conduct the particular external review based on
the nature of the health care service that is the subject of
the adverse determination or final adverse determination and
other circumstances, including conflict of interest concerns.
b. Notify the covered person or the covered person’s
authorized representative in writing that the request is
eligible and has been accepted for external review including
the name of the assigned independent review organization and
that the covered person or the covered person’s authorized
representative may submit in writing to the independent review
organization within five business days following receipt of
such notice from the commissioner, additional information
that the independent review organization shall consider
when conducting the external review. The independent review
organization may, in the organization’s discretion, accept and
consider additional information submitted by the covered person
or the covered person’s authorized representative after five
business days.
8. Within five business days after receipt of notice from
the commissioner pursuant to subsection 7, the health carrier
shall provide to the independent review organization the
documents and any information considered in making the adverse
determination or final adverse determination. Failure by the

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health carrier to provide the documents and information within
the time specified shall not delay the conduct of the external
review.
9. If the health carrier fails to provide the documents
and information within the time specified, the independent
review organization may terminate the external review and
make a decision to reverse the adverse determination or final
adverse determination. Within one business day after making
such a decision, the independent review organization shall
notify the covered person or the covered person’s authorized
representative, the health carrier, and the commissioner of its
decision.
10. The independent review organization shall review
all of the information and documents received pursuant to
subsection 8 and any other information submitted in writing
to the independent review organization by the covered person
or the covered person’s authorized representative pursuant to
subsection 7, paragraph “b” . Upon receipt of any information
submitted by the covered person or the covered person’s
authorized representative, the independent review organization
shall, within one business day, forward the information to the
health carrier. In reaching a decision the independent review
organization is not bound by any decisions or conclusions
reached during the health carrier’s internal grievance process.
11. Upon receipt of information forwarded pursuant to
subsection 10, a health carrier may reconsider its adverse
determination or final adverse determination that is the
subject of the external review.
a. Reconsideration by the health carrier of its
determination shall not delay or terminate the external review.
The external review shall only be terminated if the health
carrier decides, upon completion of its reconsideration, to
reverse its determination and provide coverage or payment for
the health care service that is the subject of the adverse
determination or final adverse determination.
b. Within one business day after making a decision
to reverse its adverse determination or final adverse
determination, the health carrier shall notify the covered
person or the covered person’s authorized representative,
the independent review organization, and the commissioner in
writing of its decision. The independent review organization
shall terminate the external review upon receipt of notice
of the health carrier’s decision to reverse its adverse

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determination or final adverse determination.
12. In addition to the documents and information provided to
the independent review organization pursuant to this section,
the independent review organization shall, to the extent the
information or documents are available and the independent
review organization considers them appropriate, 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 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
the terms 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 the federal 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 the extent
the information or documents are available and the clinical
reviewer considers them relevant.
13. a. Within forty-five days after the date of receipt
of a request for an external review, the independent review
organization shall provide written notice of its decision to
uphold or reverse the adverse determination or final adverse
determination of the health carrier to the covered person or
the covered person’s authorized representative, the health
carrier, and the commissioner.
b. The independent review organization shall include in its
decision all of the following:
(1) A general description of the reason for the request for
external review.
(2) The date the independent review organization received
the assignment from the commissioner to conduct the external

House File 597, p. 14
review.
(3) The date the external review was conducted.
(4) The date of the decision.
(5) The principal reason or reasons for its decision,
including what applicable evidence-based standards, if any,
were a basis for its decision.
(6) The rationale for its decision.
(7) References to evidence or documentation, including
evidence-based standards, considered in reaching its decision.
14. Upon receipt of notice of a decision reversing the
adverse determination or final adverse determination of the
health carrier, the health carrier shall immediately approve
the coverage that was the subject of the determination.
Sec. 8. NEW SECTION . 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 an expedited
external review at the time the covered person or the covered
person’s authorized representative 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
adverse determination would seriously jeopardize the life or
health of the covered person or would jeopardize 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 health
of the covered person or would jeopardize the covered person’s
ability to regain maximum function.
c. A final adverse determination that concerns an admission,
availability of care, continued stay, or health care service
for which the covered person received emergency services, and
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
request meets the eligibility requirements for external review
set forth in section 514J.107, subsection 3, and this section.

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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 authorized
representative of its eligibility determination including
a statement informing the covered person or the covered
person’s authorized representative of the right to appeal that
determination 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 with the terms of the
covered person’s health benefit plan and shall be subject to
all applicable provisions of this chapter. The commissioner
shall make a determination pursuant to this subsection 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
eligible for expedited external review, the commissioner shall
immediately assign an independent review organization from the
list of approved independent review organizations maintained by
the commissioner to conduct the expedited external review. The
commissioner shall then immediately notify the health carrier
and the covered person or the covered person’s authorized
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
particular external review based on the nature of the health
care service that is the subject of the adverse determination
or final adverse determination and other circumstances,
including conflict of interest 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 necessary
documents and information considered in making the adverse
determination or final adverse determination to the independent
review organization electronically or by telephone or facsimile

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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 review
organization shall consider the documents and information
provided by the health carrier, and to the extent the
information or documents are available and the independent
review organization 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 authorized
representative, 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
the terms 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 the federal 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 the extent
the information or documents are available and the clinical
reviewer considers them relevant.
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
request for expedited external review, the assigned independent
review organization shall do all of the 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

House File 597, p. 17
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 independent review organization shall provide written
confirmation of the decision to the covered person or the
covered person’s authorized representative, the health carrier,
and the commissioner that 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 the
adverse determination or final adverse determination, the
health carrier shall immediately approve the coverage that
was the subject of the adverse determination or final adverse
determination.
Sec. 9. NEW SECTION . 514J.109 External review of
experimental or investigational treatment adverse determinations.
1. Within four months after the date of receipt of a notice
of an adverse determination or final adverse determination that
involves a denial of coverage based on a determination that
the health care service or treatment recommended or requested
is experimental or investigational, a covered person or the
covered person’s authorized representative may file a request
for external review with the commissioner.
2. Within one business day after the date of receipt of the
request, the commissioner shall notify the health carrier of
the request.
3. Within five business days following the date of receipt
of notice of a request for external review pursuant to this
section, the health carrier shall complete a preliminary review
of the request to determine whether:
a. The individual is or was a covered person under the
health benefit plan at the time the health care service or
treatment was recommended or requested.
b. The recommended or requested health care service or
treatment that is the subject of the adverse determination or
final adverse determination meets the following conditions:
(1) Is a covered benefit under the covered person’s health
benefit plan except for the health carrier’s determination that
the service or treatment is experimental or investigational for
a particular medical condition.
(2) Is not explicitly listed as an excluded benefit under
the covered person’s health benefit plan with the health

House File 597, p. 18
carrier.
c. The covered person’s treating physician has certified
that one of the following situations is applicable:
(1) Standard health care services or treatments have
not been effective in improving the condition of the covered
person.
(2) Standard health care services or treatments are not
medically appropriate for the covered person.
(3) There is no available standard health care service or
treatment covered by the health carrier that is more beneficial
than the recommended or requested health care service or
treatment sought.
d. The covered person’s treating physician has certified in
writing one of the following:
(1) That the recommended or requested health care service
or treatment that is the subject of the adverse determination
or final adverse determination is likely to be more beneficial
to the covered person, in the physician’s opinion, than any
available standard health care services or treatments.
(2) The physician is a licensed, board-certified, or
board-eligible physician qualified to practice in the area of
medicine appropriate to treat the covered person’s condition,
and that scientifically valid studies using accepted protocols
demonstrate that the health care service or treatment
recommended or requested that is the subject of the adverse
determination or final adverse determination is likely to
be more beneficial to the covered person than any available
standard health care services or treatments.
e. The covered person or the covered person’s authorized
representative has exhausted the health carrier’s internal
grievance process, unless the covered person or the covered
person’s authorized representative is not required to exhaust
the health carrier’s internal grievance process pursuant to
section 514J.106 or 514J.108.
f. The covered person or the covered person’s authorized
representative has provided all the information and forms
required by the commissioner that are necessary to process an
external review pursuant to this section.
4. Within one business day after completion of the
preliminary review pursuant to subsection 3, the health
carrier shall notify the commissioner and the covered person
or the covered person’s authorized representative in writing
whether the request is complete and whether the request is

House File 597, p. 19
eligible for external review pursuant to this section. If the
request is not complete, the health carrier shall notify the
commissioner and the covered person or the covered person’s
authorized representative in writing and include in the notice
what information or materials are needed to make the request
complete. If the request is not eligible for external review,
the health carrier shall notify the covered person or the
covered person’s authorized representative and the commissioner
in writing and include in the notice the reasons for its
ineligibility.
5. 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. The
notice of initial determination shall include a statement
informing the covered person or the covered person’s authorized
representative that a health carrier’s initial determination
that the external review request is ineligible for review may
be appealed to the commissioner.
6. The commissioner may determine that a request is eligible
for external review pursuant to this section, notwithstanding
a health carrier’s initial determination that the request
is ineligible, and require that it be referred for external
review. In making this determination, the commissioner’s
decision shall be made in accordance with the terms of the
covered person’s health benefit plan and shall be subject to
all applicable provisions of this chapter.
7. Within one business day after receipt of the notice
from the health carrier that the external review request is
eligible for external review or upon a determination by the
commissioner that a request is eligible for external review,
the commissioner shall do all of the following:
a. Assign an independent review organization from the list
of approved independent review organizations maintained by the
commissioner and notify the health carrier of the name of the
assigned independent review organization.
b. Notify the covered person or the covered person’s
authorized representative in writing of the request’s
eligibility and acceptance for external review and the
name of the assigned independent review organization and
that the covered person or the covered person’s authorized
representative may submit in writing to the independent review
organization, within five business days following the date
of receipt of such notice, additional information that the

House File 597, p. 20
independent review organization shall consider when conducting
the external review. The independent review organization
may, in the organization’s discretion, accept and consider
additional information submitted by the covered person or the
covered person’s authorized representative after five business
days.
8. Within one business day after receipt of the notice
of assignment to conduct the external review, the assigned
independent review organization shall select one or more
clinical reviewers, as it determines is appropriate pursuant to
subsection 9 to conduct the external review.
9. In selecting clinical reviewers, the independent review
organization shall select physicians or other health care
professionals who meet the minimum qualifications described in
this chapter and, through clinical experience in the past three
years, are experts in the treatment of the covered person’s
condition and knowledgeable about the recommended or requested
health care service or treatment that is the subject of the
adverse determination or the final adverse determination.
Neither the covered person or the covered person’s authorized
representative nor the health carrier shall choose or control
the choice of the clinical reviewers selected to conduct the
external review.
10. Each clinical reviewer selected shall provide a written
opinion to the independent review organization regarding
whether the recommended or requested health care service or
treatment should be covered. Each clinical reviewer shall
review all of the information and documents received and any
other information submitted in writing by the covered person or
the covered person’s authorized representative. In reaching
an opinion, a clinical reviewer is not bound by any decisions
or conclusions reached during the health carrier’s internal
grievance process.
11. Within five business days after receipt of notice of the
assignment of the independent review organization, the health
carrier shall provide to the independent review organization
the documents and any information considered in making the
adverse determination or the final adverse determination.
Failure by the health carrier to provide the documents and
information within the time specified shall not delay the
conduct of the external review.
12. If the health carrier fails to provide the documents
and information within the time specified, the independent

House File 597, p. 21
review organization may terminate the external review and
make a decision to reverse the adverse determination or final
adverse determination. Within one business day after making
such a decision, the independent review organization shall
notify the covered person or the covered person’s authorized
representative, the health carrier, and the commissioner.
13. Within one business day after the receipt of any
information submitted by the covered person or the covered
person’s authorized representative, the independent review
organization shall forward the information to the health
carrier. Upon receipt of the forwarded information, the health
carrier may reconsider its adverse determination or final
adverse determination that is the subject of the external
review.
a. Reconsideration by the health carrier of its adverse
determination or final adverse determination shall not delay or
terminate the external review. The external review shall only
be terminated if the health carrier decides, upon completion
of its reconsideration, to reverse its determination and
provide coverage or payment for the recommended or requested
health care service or treatment that is the subject of the
determination.
b. Within one business day after making a decision to
reverse its determination, the health carrier shall notify
the covered person or the covered person’s authorized
representative, the independent review organization, and the
commissioner in writing of its decision. The independent
review organization shall terminate the external review upon
receipt of such notice from the health carrier.
14. a. Within twenty days after being selected to conduct
the external review, each clinical reviewer shall provide
an opinion to the assigned independent review organization
regarding whether the recommended or requested health care
service or treatment should be covered pursuant to this
section.
b. Each clinical reviewer’s opinion shall be in writing and
include the following information:
(1) A description of the covered person’s medical
condition.
(2) A description of the indicators relevant to determining
whether there is sufficient evidence to demonstrate that the
recommended or requested health care service or treatment is
likely to be more beneficial to the covered person than any

House File 597, p. 22
available standard health care services or treatments and that
the adverse risks of the recommended or requested health care
service or treatment would not be substantially increased over
those of available standard health care services or treatments.
(3) A description and analysis of any medical or scientific
evidence considered in reaching the opinion.
(4) A description and analysis of any applicable
evidence-based standards.
(5) Information on whether the reviewer’s rationale for
the opinion is based on either of the factors described in
subsection 15, paragraph “e” .
15. In addition to the documents and information provided,
each clinical reviewer, to the extent the information or
documents are available and the reviewer considers them
appropriate, shall consider all of the following in reaching
an opinion:
a. The covered person’s pertinent medical records.
b. The treating physician’s recommendation or request.
c. Consulting reports from appropriate health care
professionals and other documents submitted by the health
carrier, the covered person or the covered person’s authorized
representative, 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, but
for the health carrier’s determination that the recommended
or requested health care service or treatment that is the
subject of the opinion is experimental or investigational, the
reviewer’s opinion is not contrary to the terms of coverage
under the covered person’s health benefit plan with the health
carrier.
e. Whether either of the following factors is applicable:
(1) The recommended or requested health care service or
treatment has been approved by the federal food and drug
administration, if applicable, for the condition.
(2) Medical or scientific evidence or evidence-based
standards demonstrate that the expected benefits of the
recommended or requested health care service or treatment is
likely to be more beneficial to the covered person than any
available standard health care service or treatment and the
adverse risks of the recommended or requested health care
service or treatment would not be substantially increased over
those of available standard health care services or treatments.

House File 597, p. 23
16. a. If a majority of the clinical reviewers opine that
the recommended or requested health care service or treatment
should be covered, the independent review organization shall
make a decision to reverse the health carrier’s adverse
determination or final adverse determination.
b. If a majority of the clinical reviewers opine that the
recommended or requested health care service or treatment
should not be covered, the independent review organization
shall make a decision to uphold the health carrier’s adverse
determination or final adverse determination.
c. If the clinical reviewers are evenly split as to whether
the recommended or requested health care service or treatment
should be covered, the independent review organization shall
obtain the opinion of an additional clinical reviewer in order
for the independent review organization to make a decision
based on the opinions of a majority of the clinical reviewers.
d. The additional clinical reviewer selected shall use the
same information to reach an opinion as the clinical reviewers
who have already submitted their opinions.
e. The selection of an additional clinical reviewer under
this subsection shall not extend the time within which the
assigned independent review organization is required to make a
decision based on the opinions of the clinical reviewers for
the external review.
17. Within twenty days after it receives the opinion
of each clinical reviewer, the assigned independent review
organization shall make a decision based on the opinions of
the clinical reviewer or reviewers, to uphold or reverse the
adverse determination or final adverse determination of the
health carrier and provide written notice of the decision
to the covered person or the covered person’s authorized
representative, the health carrier, and the commissioner.
18. a. A covered person or the covered person’s authorized
representative may make a written or oral request to the
commissioner for an expedited external review of the adverse
determination or final adverse determination pursuant to
this subsection if the covered person’s treating physician
certifies, in writing, that the recommended or requested
health care service or treatment that is the subject of the
request would be significantly less effective if not promptly
initiated.
(1) Upon receipt of a request for an expedited external
review pursuant to this subsection, the commissioner shall

House File 597, p. 24
immediately notify the health carrier.
(2) Upon receipt of notice of the request for expedited
external review, the health carrier shall immediately determine
whether the request is eligible for external review as
provided in subsection 3, paragraphs “a” through “f” , and shall
immediately issue a notice of initial determination informing
the commissioner and the covered person or the covered person’s
authorized representative of its eligibility determination.
The notice of initial determination of eligibility issued by a
health carrier shall include a statement informing the covered
person or the covered person’s authorized representative that
the health carrier’s initial determination that the external
review request is ineligible for expedited external review may
be appealed to the commissioner.
(3) The commissioner may determine that a request is
eligible for external review, notwithstanding a health
carrier’s initial determination that the request is not
eligible, and refer the request for external review. In making
this determination, the commissioner’s decision shall be made
in accordance with the terms of the covered person’s health
benefit plan and shall be subject to all applicable provisions
of this chapter.
b. (1) Upon receipt of the notice of initial determination
that the request is eligible for expedited external review
or upon a determination by the commissioner that the request
is eligible for expedited external review, the commissioner
shall immediately assign an independent review organization
to conduct the expedited external review, from the list of
approved independent review organizations maintained by the
commissioner, and notify the health carrier of the name of the
assigned independent review organization.
(2) Upon receipt of notice of the independent review
organization assigned to conduct an expedited external review,
the health carrier shall provide or transmit all necessary
documents and information considered in making the adverse
determination or final adverse determination to the independent
review organization electronically or by telephone or facsimile
or any other available expeditious method.
(3) A clinical reviewer or clinical reviewers shall be
selected immediately by the independent review organization and
shall provide an opinion orally or in writing to the assigned
independent review organization as expeditiously as the covered
person’s medical condition or circumstances require, but in no

House File 597, p. 25
event more than five calendar days after being selected. If
the opinion provided was not in writing, within forty-eight
hours following the date the opinion was provided, the clinical
reviewer shall provide written confirmation of the opinion to
the assigned independent review organization and include all
required information in support of the opinion.
c. Within forty-eight hours after the date of receipt
of the opinion of each clinical reviewer, the assigned
independent review organization shall make a decision based
on the opinions of the clinical reviewer or reviewers as to
whether to reverse or uphold the adverse determination or
final adverse determination and provide notice of the decision
orally or in writing to the covered person or the covered
person’s authorized representative, the health carrier, and
the commissioner. If the notice was provided orally, within
forty-eight hours after the date of providing that notice,
the independent review organization shall provide written
confirmation of the decision to the covered person or the
covered person’s authorized representative, the health carrier,
and the commissioner.
d. The independent review organization shall include in the
notice of its decision all of the following:
(1) A general description of the reason for the request for
an expedited external review.
(2) The written opinion of each clinical reviewer,
including the recommendation of each clinical reviewer as
to whether the recommended or requested health care service
or treatment should be covered and the rationale for the
reviewer’s recommendation.
(3) The date the independent review organization was
assigned by the commissioner to conduct the expedited external
review.
(4) The date the expedited external review was conducted.
(5) The date of its decision.
(6) The principal reason or reasons for its decision.
(7) The rationale for its decision.
19. Upon receipt of notice of a decision of the independent
review organization reversing an adverse determination or final
adverse determination, the health carrier shall immediately
approve coverage of the recommended or requested health care
service or treatment that was the subject of the determination.
Sec. 10. NEW SECTION . 514J.110 Effect of external review
decision.

House File 597, p. 26
1. An external review decision pursuant to this chapter is
binding on the health carrier except to the extent the health
carrier has other remedies available under applicable Iowa law.
The external review process shall not be considered a contested
case under chapter 17A.
2. a. A covered person or the covered person’s authorized
representative may appeal the external review decision made by
an independent review organization by filing a petition for
judicial review either in Polk county district court or in
the district court in the county in which the covered person
resides. The petition for judicial review must be filed
within fifteen business days after the issuance of the review
decision. The petition shall name the covered person or the
covered person’s authorized representative, or the person’s
health care provider as the petitioner. The respondent
shall be the health carrier. The petition shall not name the
independent review organization as a party.
b. The commissioner shall not be named as a respondent
unless the petitioner alleges action or inaction by the
commissioner under the standards articulated in section
17A.19, subsection 10. Allegations against the commissioner
under section 17A.19, subsection 10, shall be stated with
particularity. The commissioner may, upon motion, intervene in
the judicial review proceeding. The findings of fact by the
independent review organization conducting the external review
are conclusive and binding on appeal.
3. The health carrier shall follow and comply with the
decision of the court on appeal. The health carrier or
treating health care provider shall not be subject to any
penalties, sanctions, or award of damages for following and
complying in good faith with the external review decision of
the independent review organization or the decision of the
court on appeal.
4. The covered person or the covered person’s authorized
representative may bring an action in Polk county district
court or in the district court in the county in which the
covered person resides to enforce the external review decision
of the independent review organization or the decision of the
court on appeal.
5. A covered person or the covered person’s authorized
representative shall not file a subsequent request for external
review involving any determination for which the covered person
or the covered person’s authorized representative has already

House File 597, p. 27
received an external review decision.
6. If a covered person dies before the completion of
the external review process, the process shall continue to
completion if there is potential liability of a health carrier
to the estate of the covered person.
7. a. If a covered person who has already received health
care services under a health benefit plan requests external
review of the plan’s adverse determination or final adverse
determination and changes to another health benefit plan before
the external review process is completed, the health carrier
whose coverage was in effect at the time the health care
service was received is responsible for completing the external
review process.
b. If a covered person who has not yet received health
care services requests external review of a health benefit
plan’s adverse determination or final adverse determination
and then changes to another plan prior to receipt of the
health care services and completion of the external review
process, the external review process shall begin anew with the
covered person’s current health carrier. In this instance,
the external review process shall be conducted as an expedited
external review.
Sec. 11. NEW SECTION . 514J.111 Approval of independent
review organizations.
1. The commissioner shall approve applications submitted by
independent review organizations to conduct external reviews
under this chapter. The commissioner may retain an outside
expert to perform reviews of such applications.
2. In order to be eligible for approval by the commissioner
to conduct external reviews, an independent review organization
shall meet all of the following requirements:
a. Be accredited by a nationally recognized private
accrediting entity that the commissioner determines has
independent review organization accreditation standards that
are equivalent to or exceed the minimum qualifications for
independent review organizations established in this chapter.
b. Submit an application in a form and format as directed by
the commissioner.
c. Meet the minimum qualifications contained in section
514J.112.
3. The commissioner may approve independent review
organizations that are not accredited by a nationally
recognized private accrediting entity if there are no

House File 597, p. 28
acceptable nationally recognized private accrediting entities
providing independent review organization accreditation.
4. The commissioner shall develop an application form for
initially approving and for reapproving independent review
organizations to conduct external reviews.
5. The commissioner may charge an initial application fee
and a renewal fee as specified by rule.
6. The approval of an independent review organization to
conduct external reviews by the commissioner pursuant to this
chapter is effective for two years, unless the commissioner
determines that the independent review organization is not
satisfying the minimum qualifications of this chapter. If the
commissioner determines that an independent review organization
has lost its accreditation or no longer satisfies the minimum
requirements established under this chapter, the commissioner
shall terminate approval of the independent review organization
to conduct external reviews and remove the independent review
organization from the list of independent review organizations
approved to conduct external reviews that is maintained by the
commissioner.
7. The commissioner shall maintain a list of currently
approved independent review organizations.
Sec. 12. NEW SECTION . 514J.112 Minimum qualifications for
independent review organizations.
1. To be approved to conduct external reviews pursuant
to this chapter, an independent review organization shall
have and maintain written policies and procedures that govern
all aspects of both the standard external review process and
the expedited external review process and that include, at a
minimum, all of the following:
a. A quality assurance mechanism that does all of the
following:
(1) Ensures that external reviews are conducted within the
specified time frames and that required notices are provided
in a timely manner.
(2) Ensures the selection of qualified and impartial
clinical reviewers to conduct external reviews on behalf of
the independent review organization and suitable matching of
reviewers to specific cases and that the independent review
organization employs or contracts with an adequate number of
clinical reviewers to meet this objective.
(3) Ensures the confidentiality of medical and treatment
records and clinical review criteria.

House File 597, p. 29
(4) Establishes and maintains written procedures to
ensure that the independent review organization is unbiased in
addition to any other procedures required under this section.
(5) Ensures that any person employed by or under contract
with the independent review organization adheres to the
requirements of this chapter.
b. A toll-free telephone service to receive information
related to external reviews twenty-four hours a day, seven days
a week, that is capable of accepting, recording, or providing
appropriate instruction to incoming telephone callers outside
normal business hours.
c. An agreement and a system to maintain required records
and provide access to those records by the commissioner.
2. Each clinical reviewer assigned by an independent review
organization to conduct external reviews shall be a physician
or other appropriate health care professional who meets all of
the following minimum qualifications:
a. Is an expert in the treatment of the covered person’s
medical condition that is the subject of the external review.
b. Is knowledgeable about the recommended or requested
health care service or treatment through recent or current
actual clinical experience treating patients with the same or
similar medical condition as the covered person.
c. Holds a nonrestricted license in a state of the United
States and, for physicians, a current certification by a
recognized American medical specialty board in the area or
areas appropriate to the subject of the external review.
d. Has no history of disciplinary actions or sanctions,
including loss of staff privileges or participation
restrictions, that have been taken or are pending by any
hospital, governmental agency or unit, or regulatory body that
raise a substantial question as to the clinical reviewer’s
physical, mental, or professional competence or moral
character.
3. An independent review organization shall not own
or control, be a subsidiary of, or in any way be owned or
controlled by, or exercise control with, a health benefit plan,
a national, state, or local trade association of health benefit
plans, or a national, state, or local trade association of
health care providers.
4. Neither the independent review organization selected to
conduct an external review nor any clinical reviewer assigned
by the independent organization to conduct an external review

House File 597, p. 30
shall have a material professional, familial, or financial
conflict of interest with any of the following:
a. The health carrier that is the subject of the external
review.
b. The covered person whose health care service or treatment
is the subject of the external review or the covered person’s
authorized representative.
c. Any officer, director, or management employee of the
health carrier that is the subject of the external review.
d. The health care professional or the health care
professional’s medical group or independent practice
association recommending the health care service or treatment
that is the subject of the external review.
e. The facility at which the recommended health care service
or treatment would be provided.
f. The developer or manufacturer of the principal drug,
device, procedure, or other therapy being recommended for the
covered person whose health care service treatment is the
subject of the external review.
5. In determining whether an independent review
organization or a clinical reviewer of the independent
review organization has a material professional, familial,
or financial conflict of interest as provided in subsection
4, the commissioner shall take into consideration situations
where the independent review organization to be assigned to
conduct an external review of a specified case or a clinical
reviewer to be assigned by the independent review organization
to conduct an external review of a specified case may have an
apparent professional, familial, or financial relationship or
connection with a person described in subsection 4, but the
characteristics of that relationship or connection are such
that they do not constitute a material professional, familial,
or financial conflict of interest that would prohibit selection
of the independent review organization or the clinical reviewer
to conduct the external review.
6. a. An independent review organization that is accredited
by a nationally recognized private accrediting entity that
has independent review accreditation standards that the
commissioner has determined are equivalent to or exceed the
minimum qualifications of this section shall be presumed to be
in compliance with the requirements of this section.
b. The commissioner shall initially and periodically review
the standards of each nationally recognized private accrediting

House File 597, p. 31
entity that provides accreditation to independent review
organizations to determine whether the accrediting entity’s
standards are, and continue to be, equivalent to or exceed the
minimum qualifications established under this section. The
commissioner may accept a review of those standards conducted
by the national association of insurance commissioners for the
purpose of making a determination under this subsection.
c. Upon request, a nationally recognized private accrediting
entity shall make its current independent review organization
accreditation standards available to the commissioner or
to the national association of insurance commissioners in
order for the commissioner to determine if the accrediting
entity’s standards are equivalent to or exceed the minimum
qualifications established under this section. The
commissioner may exclude consideration of accreditation of
independent review organizations by any private accrediting
entity whose standards have not been reviewed by the national
association of insurance commissioners.
Sec. 13. NEW SECTION . 514J.113 Immunity for independent
review organizations.
An independent review organization, a clinical reviewer
working on behalf of an independent review organization, or
an employee, agent, or contractor of an independent review
organization shall not be liable in damages to any person for
any opinions rendered or acts or omissions performed within the
scope of the duties of the organization, the clinical reviewer,
or an employee, agent, or contractor of the organization under
this chapter during, or upon completion of, an external review
conducted pursuant to this chapter, unless the opinion was
rendered or the act or omission was performed in bad faith or
involved gross negligence.
Sec. 14. NEW SECTION . 514J.114 External review reporting
requirements.
1. a. An independent review organization assigned to
conduct an external review shall maintain written records in
the aggregate by state and by health carrier of all requests
for external review for which it conducted an external review
during a calendar year.
b. Each independent review organization required to maintain
written records pursuant to this section shall submit to the
commissioner, upon request, a report in the format specified by
the commissioner. The report shall include in the aggregate by
state and by health carrier all of the following:

House File 597, p. 32
(1) The total number of requests for external review
assigned to the independent review organization.
(2) The average length of time for resolution of each
request for external review assigned to the independent review
organization.
(3) A summary of the types of coverages or cases for which
an external review was requested, in the format required by the
commissioner by rule.
(4) Any other information required by the commissioner.
c. The independent review organization shall retain the
written records for at least three years.
2. a. Each health carrier shall maintain written records
in the aggregate by state and by type of health benefit plan
offered by the health carrier of all requests for external
review that the health carrier receives notice of from the
commissioner pursuant to this chapter.
b. Each health carrier required to maintain written records
of requests for external review pursuant to this subsection
shall submit to the commissioner, upon request, a report in the
format specified by the commissioner. The report shall include
in the aggregate by state and by type of health benefit plan
offered all of the following:
(1) The total number of requests for external review of
the health carrier’s adverse determinations and final adverse
determinations.
(2) Of the total number of requests for external review, the
number of requests determined eligible for external review.
(3) The number of requests for external review resolved
and, of those resolved, the number resolved upholding the
adverse determination or final adverse determination of the
health carrier and the number resolved reversing the adverse
determination or final adverse determination of the health
carrier.
(4) The number of external reviews that were terminated as
the result of a reconsideration by the health carrier of its
adverse determination or final adverse determination after the
receipt of additional information from the covered person or
the covered person’s authorized representative.
(5) Any other information the commissioner may request or
require.
c. The health carrier shall retain the written records for
at least three years.
Sec. 15. NEW SECTION . 514J.115 Expenses of external review.

House File 597, p. 33
The health carrier against which a request for a standard
external review or an expedited external review is filed shall
pay the costs of retaining an independent review organization
to conduct the external review.
Sec. 16. NEW SECTION . 514J.116 Disclosure requirements.
1. Each health carrier shall include a description of
the external review procedures contained in this chapter in
or attached to any policy, certificate, membership booklet,
outline of coverage, or other evidence of coverage that is
provided to a covered person. The description shall be in a
format prescribed by the commissioner by rule.
2. The description required by subsection 1 shall include
a statement that informs the covered person of the right of
the covered person to file a request for an external review
of an adverse determination or final adverse determination of
the health carrier with the commissioner. The statement shall
explain that external review is available when the adverse
determination or final adverse determination involves an issue
of medical necessity, appropriateness, health care setting,
level of care, or effectiveness. The statement shall include
the telephone number and address of the commissioner. The
statement shall also inform the covered person that when filing
a request for external review, the covered person will be
required to authorize the release of any medical records of
the covered person that may be required to be reviewed for the
purpose of reaching a decision on the request for external
review.
Sec. 17. NEW SECTION . 514J.117 Rulemaking authority.
The commissioner may adopt rules pursuant to chapter 17A to
carry out the provisions of this chapter.
Sec. 18. NEW SECTION . 514J.118 Severability.
If any provision of this chapter, or the application of the
provision to any person or circumstance is held invalid, the
remainder of the chapter, and the application of the provision
to persons or circumstances other than those to which it is
held invalid, shall not be affected.
Sec. 19. NEW SECTION . 514J.119 Penalties.
A person who fails to comply with the provisions of this
chapter or the rules adopted pursuant to this chapter is
subject to the penalties provided under chapter 507B.
Sec. 20. NEW SECTION . 514J.120 Applicability.
1. This chapter applies to all requests for external review
filed on or after July 1, 2011.

House File 597, p. 34
2. Section 514J.116 applies to all health benefit plans
delivered, issued for delivery, continued, or renewed in this
state on or after July 1, 2011.
Sec. 21. REPEAL. Sections 514J.1 through 514J.15, Code
2011, are repealed.
Sec. 22. TRANSITION PROVISION —— APPLICABILITY TO PRIOR
REQUESTS. Sections 514J.1 through 514J.15, Code 2011, are
applicable to all requests for external review filed prior to
July 1, 2011.
______________________________
KRAIG PAULSEN
Speaker of the House
______________________________
JOHN P. KIBBIE
President of the Senate
I hereby certify that this bill originated in the House and
is known as House File 597, Eighty-fourth General Assembly.
______________________________
W. CHARLES SMITHSON
Chief Clerk of the House
Approved _______________, 2011
______________________________
TERRY E. BRANSTAD
Governor