Iowa Admin. Code r. 191 app A
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.
Iowa Admin. Code r. 191 app A