Iowa Admin. Code r. 191-39.53 - Additional requirements

The independent review entity shall develop and maintain written policies and procedures governing all aspects of the independent review process. The written policies and procedures include, but are not limited to, the following:

(1) Procedures to ensure that independent reviews are conducted within the time frames specified in this division and Iowa Code chapter 514G as amended by 2008 Iowa Acts, House File 2694, and that any required notices are provided in a timely manner.

(2) Procedures to ensure the selection of qualified and impartial reviewers. The reviewers shall be qualified to render impartial determinations relating to the benefit trigger which is the subject of the benefit trigger decision under review (e.g., assessment of cognitive impairment or inability to perform activities of daily living due to a loss of functional capacity) and be deemed experts in the assessment of such benefit trigger.

(3) Procedures to ensure that the insured is notified in writing of the insured's right to object to the independent review entity selected by the insurer or to the licensed health care professional designated by the independent review entity to conduct the review by filing a notice of objection, along with the reasons for the objection, with the commissioner at the Iowa Insurance Division, 1963 Bell Avenue, Suite 100, Des Moines, Iowa 50315, within ten days of the receipt of a notice from the independent review entity.

(4) Procedures to ensure the confidentiality of protected health information records and review materials, in accordance with federal and state law.

(5) Procedures to ensure adherence to the requirements of this division and Iowa Code chapter 514G by any contractor, subcontractor, subvendor, agent or employee affiliated with the independent review entity.

(6) Policies and procedures establishing a quality assurance program. The program shall include a written description to be provided to all individuals involved in the program, the organizational arrangements, and the ongoing procedures for the identification, evaluation, resolution and follow-up of potential and actual problems in independent reviews performed by the independent review entity and procedures to ensure the maintenance of program standards pursuant to this requirement.

Notes

Iowa Admin. Code r. 191-39.53

Amended by IAB November 20, 2019/Volume XLII, Number 11, effective 12/25/2019 Amended by IAB May 5, 2021/Volume XLIII, Number 23, effective 6/9/2021