514J.102 Definitions.
As used in this chapter, unless the context otherwise requires:
1. a. “”Adverse determination”” means a determination by a health carrier that an admission, availability of care, continued stay, or other health care service, other than a dental 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.
b. For the purposes of denial of a dental care service, “”adverse determination”” means a determination by a health carrier that a dental 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, and the requested service or payment for the service is therefore denied, reduced, or terminated in whole or in part.
c. “”Adverse determination”” does not include a denial of coverage for a service or treatment specifically listed in plan or evidence of 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, enrollee, or other individual participating in a health benefit plan.
12. “”Dental care services”” means diagnostic, preventive, maintenance, and therapeutic dental care that is provided in accordance with chapter 153.
13. “”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.
14. “”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.

§514J.102, EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS 2

15. “”Emergency services”” means health care items and services furnished or required to evaluate and treat an emergency medical condition.
16. “”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.
17. “”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.
18. “”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.
19. “”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.
20. “”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.
21. “”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.
22. “”Health care provider”” or “”provider”” means a health care professional or a facility.
23. “”Health care services”” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. “”Health care services”” includes dental care services.
24. “”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.
25. “”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.
26. “”Independent review organization”” means an entity that conducts independent external reviews of adverse determinations and final adverse determinations.
27. “”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 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 EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS, §514J.102

(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””.
28. “”NAIC”” means the national association of insurance commissioners.
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 specific intervention, which includes study of the groups for variables and anticipated outcomes over time.
2011 Acts, ch 101, §2; 2014 Acts, ch 1140, §108 – 110; 2017 Acts, ch 148, §93, 94
Referred to in §155A.48, 505.26, 514C.34, 514F.7, 514F.8, 686D.2