Utilization review is conducted to determine the appropriateness of levels of treatment and of giving opinions as to the reasonableness of charges for diagnostic or treatment services of the licensees of certain licensing boards (e.g., Board of Medicine, Iowa Code Chapter 148; Board of Podiatry, Iowa Code Chapter 149; Board of Chiropractic, Iowa Code Chapter 151; and Board of Nursing, Iowa Code Chapter 152).  The licensing boards can establish their own committees to do the utilization review, or they can designate other utilization organizations to do it for them.  Under Iowa law, insurers or other plan providers are not permitted to conduct utilization reviews, either directly or indirectly, under a contract with a third party utilization review organization that does not meet requirements established for accreditation set by the utilization review accreditation commission or the national committee on quality assurance.  Iowa Code chapter 514F and Iowa Administrative Code rule 191-70 provide more information about use and accreditation of utilization review organizations.

Each year, prior to March 1, an entity conducting utilization review shall provide the commissioner with a certification that the entity is in compliance with Iowa Administrative Code chapter 191-70.

 

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If you need assistance, please contact the Iowa Insurance Division.