Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Appendix B - External Review Request Form

Current through Register Vol. 47, No. 3, July 24, 2024
SECTION 1. ELIGIBILITY FOR EXTERNAL
				  REVIEW
This External Review Request Form must be filed with the Iowa
				  Insurance Division within
four months
after your health carrier
				  denied, reduced or terminated the requested health care service or treatment or
				  payment for the service or treatment. You or your authorized representative may
				  request an external review under any of the following circumstances:
1. Your health carrier has made a determination that an
				  admission, availability of care, continued stay, or other health care service
				  that is a covered benefit 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.
Please follow the directions in
				  Sections 1 and 2, then submit completed Sections 3 and 4, Section 5 if
				  applicable, and Section 7 if you are requesting an expedited
				  review.
2. Your health carrier has made a denial of coverage based on
				  a determination that the health care service or treatment recommended or
				  requested is experimental or investigational.
Please follow the
				  directions in Sections 1 and 2, then submit completed Sections 3 and 4, Section
				  5 if applicable, Section 6, and Section 7 if you are requesting an expedited
				  review.
3. The final adverse determination concerns an admission,
				  availability of care, continued stay, or a health care service for which you
				  received emergency services, but you have not been discharged from a facility.
Please follow the directions in Sections 1 and 2, then submit completed
				  Sections 3 and 4, Section 5 if applicable, and Section 7.
If coverage was denied for a service or treatment
				  specifically listed in your health insurance policy as excluded from coverage
				  (other than what is listed in paragraphs 1 and 2 above), you will not be
				  eligible for external review.
You also will need to have completed any internal appeals
				  with your health carrier before you can request an external review,
				  unless:
1. You already did request an internal appeal with your
				  health carrier and have not received a decision and it has been 30 days since
				  you requested the appeal; or
2. Your health carrier has waived the requirement that you
				  complete an internal appeal before requesting an external review; or
3. You need an expedited review because time is a factor in
				  your treatment.
SECTION 2. WHAT TO SEND AND WHERE TO SEND
				  IT
YOU MUST SUBMIT ITEMS 1 AND 2 BELOW:
1. This External Review Request Form, signed and dated, with
				  the sections completed for your particular situation as described in Section 1.
				  If you would like help completing your external review request for submission,
				  contact the Market Regulation Bureau of the Iowa Insurance Division by calling
				  515-654-6600, or by email at
iid.marketregulation@iid.iowa.gov
.
2. One of the following:
a. The letter from the covered person's health carrier or
				  utilization review company that states that the decision is final and that the
				  covered person or the covered person's authorized representative has exhausted
				  all internal appeal procedures;
b. The letter from the covered person's health carrier or
				  utilization review company that states it has waived the requirement to exhaust
				  all of the health carrier's internal appeal procedures;
c. A copy of the covered person's or the covered person's
				  authorized representative's request for internal appeal and a statement that no
				  decision from the health carrier has been received for 30 days; or
d. A completed request for expedited review, Section 7 of
				  this form.
WHERE TO SEND IT:
If you are requesting a standard external review, send all
				  paperwork to the Iowa Insurance Division, 1963 Bell Avenue, Suite 100, Des
				  Moines, Iowa 50315; facsimile 515-654-6500; email
iid.marketregulation@iid.iowa.gov
. If you have
				  questions, telephone 877-955-1212 or 515-654-6600.
If you are requesting an expedited external
				  review,
call the Iowa Insurance Division (telephone 877-955-1212 or
				  515-654-6600) before sending your paperwork, and you will receive instructions
				  on the quickest way to submit the application and supporting
				  information.
SECTION 3. INFORMATION REQUIRED FOR ALL EXTERNAL REVIEW
				  REQUESTS
APPLICANT NAME
The applicant is a:
[] Covered Person/patient
[] Provider (the covered person/patient must complete section
				  4)
[] Authorized Representative (submit completed Sections 4 and
				  5)
COVERED PERSON/PATIENT INFORMATION
Covered Person's/Patient's Name:
Address:
Telephone Number:
Daytime:
Evening:
Email Address:
Fax Number:
INSURANCE INFORMATION
Name of Insurer or HMO:
Covered Person's Insurance ID Number and/or Policy
				  Number:
Insurance Claim/Reference Number:
Insurer/HMO Mailing Address:
Insurer/HMO Telephone Number:
Insurer/HMO Email Address:
Insurer/HMO Fax Number:
EMPLOYER INFORMATION
Employer's Name:
Is the health coverage that you have through your employer a
				  self-funded plan? (Y/N)________.
Some self-funded plans may voluntarily provide external
				  review, but may have different procedures.
You should check with your employer.
HEALTH CARE PROVIDER INFORMATION
Treating Physician/Health Care Provider:
Address:
Contact Person:
Telephone Number:
Email Address:
Fax Number:
Patient Medical Record Number:
REASON FOR HEALTH CARRIER'S DENIAL
(Please check one.)
[] the health care service or treatment was denied due to
				  medical necessity, appropriateness, health care setting, level of care or
				  effectiveness.
[] the health care service or treatment is experimental or
				  investigational (submit completed section 6).
[] other:
				  _________________________________________________________________________.
SUMMARY OF EXTERNAL REVIEW REQUEST
Enter a brief description of the claim and the request for
				  health care service or treatment that was denied and attach a copy of the
				  denial from your health carrier.
HEALTH CARE SERVICE OR TREATMENT DECISION IN
				  DISPUTE
Describe in your own words the health care service or
				  treatment decision in dispute and why you are appealing this denial. Indicate
				  clearly the services being denied and the specific dates for the services being
				  denied. Explain why you disagree. Attach additional pages if necessary and
				  include available pertinent medical records, any information you received from
				  your health carrier concerning the denial, any pertinent peer literature or
				  clinical studies, and any additional information from your physician or health
				  care provider that you want the independent review organization to
				  consider.
SECTION 4. SIGNATURE AND RELEASE OF MEDICAL
				  RECORDS
To appeal your health carrier's denial, you must sign and
				  date this external review request form and consent to the release of medical
				  records.
I, _______________________________, hereby request an
				  external review. I attest that the information provided in this application is
				  true and accurate to the best of my knowledge. I authorize my insurance company
				  and my health care providers to release all relevant medical or treatment
				  records to the independent review organization. I understand that the
				  independent review organization will use this information to make a
				  determination on my external review and that the information will be kept
				  confidential and will not be released to anyone else. This release is valid for
				  one year.
_________________________________________________________
Signature of covered person/patient or legal representative
				  (parent, guardian, conservator or other - please specify)
Date:
SECTION 5. APPOINTMENT OF AUTHORIZED
				  REPRESENTATIVE
(Fill out this section only if someone else will be
				  representing you in this request for external review.)
You can represent yourself, or you may ask another person,
				  including your treating health care provider, to act as your authorized
				  representative. You may revoke this authorization at any time.
I hereby authorize ___________________________________ to
				  pursue my external review request on my behalf.
______________________________________________________
Signature of covered person/patient or legal representative
				  (parent, guardian, conservator or other - please specify)
Date:
Address of Authorized Representative:
Authorized Representative's Telephone Number:
Daytime:
Evening:
Fax Number:
Email Address:
SECTION 6. REQUEST FOR EXTERNAL REVIEW OF DENIALS BASED
				  ON THE REASON THAT THE TREATMENT WAS EXPERIMENTAL OR
				  INVESTIGATIONAL
PHYSICIAN CERTIFICATION: EXPERIMENTAL OR
				  INVESTIGATIONAL DENIALS
(To Be Completed by Treating Physician)
I hereby certify that I am the treating physician for
				  ____________________________ (covered person's/patient's name) and that I have
				  requested the authorization for a drug, device, procedure or therapy denied for
				  coverage due to the insurance carrier's determination that the proposed therapy
				  is experimental and/or investigational. I understand that in order for the
				  covered person/patient to obtain the right to an external review of this
				  denial, as treating physician I must certify that the covered
				  person's/patient's medical condition meets certain requirements:
In my medical opinion as the insured's treating
				  physician, I hereby certify to the following:
(
NOTE:
Requirements 1 through 3 below must all
				  apply for the covered person/patient to qualify for an external review.)
1. The covered person/patient has a condition that qualifies
				  under one or more of the following descriptions.
(Please check all descriptions that apply.)
[] standard health care services or treatments have not been
				  effective in improving the covered person's/patient's condition.
[] Standard health care services or treatments are not
				  medically appropriate for the covered person/patient.
[] There is no available standard health care service or
				  treatment covered by the health carrier that is more beneficial than the
				  requested or recommended health care service or treatment.
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.
3. Scientifically valid studies using accepted protocols
				  demonstrate that the health care service or treatment recommended or that is
				  the subject of the adverse determination or final adverse determination is
				  likely to be more beneficial to the covered person/patient than any available
				  standard health care services or treatments.
Explain:
Please provide a description of the recommended or requested
				  health care service or treatment that is the subject of the denial. (Attach
				  additional information as necessary.)
Physician's Signature_______________________________________
				  Date: _______________
Physician's Name (Please
				  print.)____________________________________________________
SECTION 7. REQUEST FOR EXPEDITED EXTERNAL
				  REVIEW
CERTIFICATION OF TREATING HEALTH CARE PROVIDER FOR
				  EXPEDITED EXTERNAL REVIEW REQUEST
(To Be Completed by Treating Health Care
				  Provider)
NOTE TO THE TREATING HEALTH CARE
				  PROVIDER:
The standard external review process can take up to 60 days
				  from the date the patient's request for external review is received by the Iowa
				  Insurance Division.
The independent review organization should complete an
				  expedited external review within 72 hours.
This form is for the purpose of providing the certification
				  necessary to trigger expedited review.
CERTIFICATION
I hereby certify that I am a treating health care provider
				  for the patient, ___________________; and that one of the following is true:
				  (Please check all that apply.)
[] adherence to the time frame for conducting a standard
				  external review of the patient's appeal would, in my professional judgment,
				  seriously jeopardize the life or health of the patient or would jeopardize the
				  patient's ability to regain maximum function.
[] the recommended or requested health care service or
				  treatment that is the subject of the external review request would be
				  significantly less effective if not promptly initiated.
[] the final adverse determination concerns an admission,
				  availability of care, continued stay, or a health care service for which the
				  patient received emergency services, but has not been discharged from a
				  facility.
For this reason, the patient's appeal of the denial by the
				  patient's health carrier of the requested health care service or course of
				  treatment should be processed on an expedited basis.
Treating Health Care Provider's
				  Signature_________________________ Date______________ Treating Health Care
				  Provider's Name (Please print.) __________________________________ Provider's
				  Mailing Address:
Telephone Number:
Email Address:
Fax Number:
Licensure and Area of Clinical Specialty: