Iowa Code 514J.114 – External review reporting requirements
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Terms Used In Iowa Code 514J.114
- following: when used by way of reference to a chapter or other part of a statute mean the next preceding or next following chapter or other part. See Iowa Code 4.1
- person: means individual, corporation, limited liability company, government or governmental subdivision or agency, business trust, estate, trust, partnership or association, or any other legal entity. See Iowa Code 4.1
- Rule: includes "regulation". See Iowa Code 4.1
- state: when applied to the different parts of the United States, includes the District of Columbia and the territories, and the words "United States" may include the said district and territories. See Iowa Code 4.1
- year: means twelve consecutive months. See Iowa Code 4.1
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:
(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.
2011 Acts, ch 101, §14
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:
(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.
2011 Acts, ch 101, §14