514F.4 Utilization review requirements.
1. A third-party payor which provides health benefits to a covered individual residing in this state shall not conduct utilization review, either directly or indirectly, under a contract with a third-party who does not meet the requirements established for accreditation by the utilization review accreditation commission, national committee on quality assurance, or another national accreditation entity recognized and approved by the commissioner.
2. This section does not apply to any utilization review performed solely under contract with the federal government for review of patients eligible for services under any of the following:
a. Tit. XVIII of the federal Social Security Act.
b. The civilian health and medical program of the uniformed services.
c. Any other federal employee health benefit plan.
3. For purposes of this section, unless the context otherwise requires:
a. “Third-party payor” means:
(1) An insurer subject to chapter 509 or 514A.
(2) A health service corporation subject to chapter 514.
(3) A health maintenance organization subject to chapter 514B.
(4) A preferred provider arrangement.
(5) A multiple employer welfare arrangement.
(6) A third-party administrator.
(7) A fraternal benefit society.
(8) A plan established pursuant to chapter 509A for public employees.
(9) Any other benefit program providing payment, reimbursement, or indemnification for health care costs for an enrollee or an enrollee’s eligible dependents.
b. “Utilization review” means a program or process by which an evaluation is made of the necessity, appropriateness, and efficiency of the use of health care services, procedures, or facilities given or proposed to be given to an individual within this state. Such evaluation does not apply to requests by an individual or provider for a clarification, guarantee, or statement of an individual’s health insurance coverage or benefits provided under a health insurance policy, nor to claims adjudication. Unless it is specifically stated, verification of benefits, preauthorization, or a prospective or concurrent utilization review program or process shall not be construed as a guarantee or statement of insurance coverage or benefits for any individual under a health insurance policy.
99 Acts, ch 41, §5; 2010 Acts, ch 1061, §180
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