Iowa law sets rules for health plan reviews and care approvals

A utilization review organization must use a qualified medical reviewer or clinical peer to deny or lower a prior authorization request. These rules apply to requests under specified Iowa health insurance and public employee plans; listed types of coverage, including dental and vision plans, are excluded. For a physician’s request, the decision must be made by a physician with the required specialty and expertise; for another provider’s request, a clinical peer with relevant experience must decide. The organization must give the provider written reasons, appeal instructions, and a signed statement about the reviewer’s qualifications. At the provider’s request, it must hold a consultation within seven business days after notice of a denial. A provider or covered person may appeal, and a different qualified reviewer or clinical peer must handle the appeal. Applies to requests made on or after January 1, 2027, under covered plans delivered, renewed, or continued in Iowa on or after that date.

A utilization review organization may use artificial intelligence for an initial prior authorization review, but it cannot rely on it alone for certain denials or downgrades. This rule covers utilization review organizations handling prior authorization requests. For requests based on medical necessity, an artificial intelligence system cannot be the sole basis for denying, delaying, or lowering the requested service.

Health carriers must follow limits on provider penalties and interference, and utilization review organizations must meet deadlines and appeal rules for claim audits. The carrier rules concern health carriers and providers. The audit rules cover specified health plans and claims submitted by providers. Carriers cannot penalize providers for referring patients to or affiliating with out-of-network providers, interfere with staffing or referral decisions except as law allows, or offer or enforce provider agreements without giving providers an opportunity to negotiate. For audits, organizations must notify providers within 15 days after selecting a claim and decide within 45 days after receiving all requested records. Providers may appeal an adverse decision within 30 days, and the organization must decide that appeal within 30 days. After a hearing, if the insurance commissioner finds an audit rule was violated, the organization must approve and promptly pay the claim with 10 percent annual interest. The audit rules do not cover claims under active state or federal fraud investigation. The audit rules apply to audits started on or after January 1, 2027, for covered plans delivered, renewed, or continued in Iowa on or after that date.

Health plans and state health programs cannot require prior approval or extra review for certain cancer screenings and life-threatening emergencies during inpatient care. The rules cover eligible people in specified health plans, Iowa Medical Assistance, and the Hawki program. A cancer screening must be recommended by the person’s health care professional under the specified national cancer guidelines. An emergency must arise during inpatient care that meets inpatient standards, and a health professional must reasonably judge it life-threatening without immediate assessment and treatment. The rules cover specified health plans, Iowa Medical Assistance, and the Hawki program; listed insurance types are excluded from the health plan rules. Applies to covered plans and contracts delivered, renewed, or continued on or after January 1, 2027, and to requests made on or after that date.