Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Appendix A - Notice of Appeal Rights

Current through Register Vol. 47, No. 3, July 24, 2024
You have a right to appeal any decision we make that
				  denies payment on your claim or your request for coverage of a health care
				  service or treatment.
You may request additional explanation when your claim
				  or request for coverage of a health care service or treatment is denied or the
				  health care service or treatment you received was not fully covered.
Contact us when you:
* do not understand the reason for denial;
* do not understand why the health care service or treatment
				  was not fully covered;
* Do not understand why a request for coverage of a health
				  care service or treatment was denied;
* Cannot find the applicable provision in your Benefit Plan
				  Document;
* Want a copy (free of charge) of the guidelines, criteria or
				  clinical rationale that we used to make our decision; or
* Disagree with the denial or the amount not covered and you
				  want to appeal.
If your claim was denied due to missing or incomplete
				  information, you or your health care provider may resubmit the claim to us with
				  the necessary information to complete the claim.
Internal Appeal:
All appeals to us for claim
				  denials (or any decision that does not cover expenses you believe should have
				  been covered) must be sent to [insert address of the health carrier contact
				  person where appeals should be sent] within
180 days
of the date
				  you receive our denial. We will provide a full and fair review of your claim by
				  individuals associated with us, but who were not involved in making the initial
				  denial of your claim. You may provide us with additional information that
				  relates to your claim, and you may request copies of information that we have
				  that pertains to your claim. We will notify you of our decision in writing
				  within
30 days
of receiving your appeal. If you do not receive our
				  decision within
30 days
of receiving your appeal, you may be
				  entitled to file a request for external review.
External Review:
We have denied your request for
				  the provision of or payment for a health care service or course of treatment.
				  If our decision involved making a judgment as to the medical necessity,
				  appropriateness, health care setting, level of care or effectiveness of the
				  health care service or treatment you requested,
you may have a right to
				  have our decision reviewed
by health care professionals who have no
				  association with us. Requests for external review may be submitted to the
				  Commissioner of Insurance.
You may obtain an external review if:
* our decision involved the admission, availability of care,
				  continued stay, or other health care service that is a covered benefit;
				  and
* we denied, reduced or terminated the requested service or
				  treatment or payment for the service or treatment because we determined it did
				  not meet our requirements for medical necessity, health care setting, level of
				  care or effectiveness of the health care service or treatment you
				  requested.
* you have a medical condition that would seriously
				  jeopardize your life or health or would jeopardize your ability to regain
				  maximum function. In this situation, you may file a request for an
expedited external review
of our denial.
* 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.
				  In this situation, you or your authorized representative may request an
expedited external review
.
* our denial to provide or pay for health care service or
				  course of treatment is based on a determination that the service or treatment
				  is experimental or investigational. In addition, if your treating health care
				  professional certifies in writing that the recommended or requested health care
				  service or treatment that is the subject of the recommendation or request would
				  be significantly less effective if not promptly initiated, then you or your
				  authorized representative may request an
expedited external
				  review
.
You can obtain a copy of the External Review Request Form
				  from: the Iowa Insurance Division, 1963 Bell Avenue, Suite 100, Des Moines,
				  Iowa 50315; telephone 877-955-1212 or 515-654-6600; facsimile 515-654-6500;
				  website
iid.iowa.gov
.
Within
four months
after receipt of our notice
				  containing the final adverse determination and this Notice of Appeal Rights,
				  you should submit a request for external review to the Iowa Insurance Division,
				  1963 Bell Avenue, Suite 100, Des Moines, Iowa 50315; telephone 877-955-1212 or
				  515-654-6600; facsimile 515-654-6500; email
iid.marketregulation@iid.iowa.gov
.
For standard external review, a decision will be made within
45 days
after the independent review organization receives your
				  request.
For details, please review your Benefit Plan Document,
				  contact us, or contact the Iowa Insurance Division.