External review assures that a person covered by a health benefit plan has the opportunity for an independent review of an insurance company’s determination that a service for which the individual filed a benefit claim did not meet an insurance company’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and that as a result the requested payment for the service was denied, reduced, or terminated by the insurance company. External review also is available when an insurance company denies benefits for services because it determined that the services were experimental or investigational.
If you wish to file a request for an external review of an adverse determination by a health insurance company, you may do so by completing and submitting this form to the Iowa Insurance Division as directed in the instructions. An authorized representative of the person covered by the plan may make a request for an external review. The cost of the external review is paid by the insurance company.
In situations when time could seriously jeopardize the life or health of the patient or would jeopardize the patient’s ability to regain maximum function, the service would be significantly less effective if not promptly initiated, or if the determination concerns admission or availability of care, an expedited external review is available. A treating health care provider may call the Iowa Insurance Division to verbally request this process. A treating health care provider must certify the need for expedited external review.
After you submit an external review request, the Iowa Insurance Division will send you a letter detailing which Independent Review Organization has been assigned to your external review as well as some additional instructions. At that time, you will be able to send directly to the Independent Review Organization any additional information supporting your benefit claim.
The Independent Review Organization will have up to 45 days to issue a decision for the external review. If the external review is expedited the decision must be provided within 72 hours. The Independent Review Organization will notify you directly of its decision.
A list of independent review organizations utilized by the Iowa Insurance Division can be found here or in the data set below.
If you need assistance, please contact the Iowa Insurance Division.