WHAT THIS BILL REGULATES · 1 REQUIREMENT TYPE
How Is This Bill Enforced
Verbatim statutory text on the left; plain-language analysis and a per-section checklist on the right. Numbered markers cross-link to the matching checklist row.
2A 1 A utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) may use an artificial intelligence-based algorithm or system to provide an initial review of a request for prior authorization, except that, for a prior authorization request for a health care service based on medical necessity, a utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) shall not use an artificial intelligence-based algorithm or system as the sole basis for the utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k)'s decision to deny, delay, or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b) the prior authorization request.
This provision permits utilization review organizations to use AI-based algorithms or systems for an initial review of prior authorization requests but prohibits AI from serving as the sole basis for denying, delaying, or downgrading a medical-necessity prior authorization. The restriction creates a floor requirement that a human clinician must independently support any adverse determination on medical-necessity grounds, while allowing AI to play an assistive screening role.
(1) As used in this section, unless the context otherwise requires: a. "AuditAudit"Audit" means a review, investigation, or request for additional documentation by a utilization review organization before or after issuing payment on a claim to a health care provider.Iowa Code § 514F.8C(1)(a)" means a review, investigation, or request for additional documentation by a utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) before or after issuing payment on a claim to a health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c). b. "CommissionerCommissioner"Commissioner" means the commissioner of insurance.Iowa Code § 514F.8C(1)(b)" means the commissioner of insurance. c. "Health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c)" means the same as defined in section 514F.8. d. "Health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(d), § 514F.8D(1)(b)" means the same as defined in section 514F.8. e. "Utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k)" means the same as defined in section 514F.8.
(2)(a) 2 A utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) that conducts an auditAudit"Audit" means a review, investigation, or request for additional documentation by a utilization review organization before or after issuing payment on a claim to a health care provider.Iowa Code § 514F.8C(1)(a) shall notify the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) that submitted the claim of the initiation of the auditAudit"Audit" means a review, investigation, or request for additional documentation by a utilization review organization before or after issuing payment on a claim to a health care provider.Iowa Code § 514F.8C(1)(a) no later than fifteen calendar days after the date the utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) selects the claim for auditAudit"Audit" means a review, investigation, or request for additional documentation by a utilization review organization before or after issuing payment on a claim to a health care provider.Iowa Code § 514F.8C(1)(a).
(2)(b) 3 A utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) shall complete an audit of a claim and issue a determination on the claim to the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) that submitted the claim no later than forty-five calendar days after the date that the utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) receives all requested documentation regarding the claim from the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c).
(2)(c) A health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) that submitted a claim that is the subject of an auditAudit"Audit" means a review, investigation, or request for additional documentation by a utilization review organization before or after issuing payment on a claim to a health care provider.Iowa Code § 514F.8C(1)(a) by a utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) that receives an adverse determination regarding the claim may appeal the adverse determination no later than thirty calendar days after the date the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) receives the auditAudit"Audit" means a review, investigation, or request for additional documentation by a utilization review organization before or after issuing payment on a claim to a health care provider.Iowa Code § 514F.8C(1)(a) determination.
(2)(d) 4 A utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) shall consider an appeal under paragraph "c" and issue a final determination on the claim that is the subject of the appeal no later than thirty calendar days after the date the utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) receives notice of the appeal.
(2)(e) If, after a hearing, the commissionerCommissioner"Commissioner" means the commissioner of insurance.Iowa Code § 514F.8C(1)(b) finds that a utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) has violated this subsection, the claim shall be approved by the utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) and promptly paid, including interest at the rate of ten percent per annum.
(3) A health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) may opt-in to receive electronic delivery of notices and auditAudit"Audit" means a review, investigation, or request for additional documentation by a utilization review organization before or after issuing payment on a claim to a health care provider.Iowa Code § 514F.8C(1)(a) determinations from a utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k). A utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) may determine the method by which a health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) may opt-in.
(4)–(6) This section applies to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2027: (1) Individual or group accident and sickness insurance providing coverage on an expense-incurred basis. (2) An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A. (3) An individual or group health maintenance organization contract regulated under chapter 514B. (4) A plan established for public employees pursuant to chapter 509A. This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner of insurance, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers' compensation or similar insurance, or automobile medical payment insurance. This section shall apply to an auditAudit"Audit" means a review, investigation, or request for additional documentation by a utilization review organization before or after issuing payment on a claim to a health care provider.Iowa Code § 514F.8C(1)(a) initiated on or after January 1, 2027. This section shall not apply to a claim that is under active fraud investigation by a state or federal authority.
Section 514F.8C creates a new procedural framework governing audits conducted by utilization review organizations. It imposes a 15-calendar-day notice requirement after claim selection, a 45-calendar-day completion deadline after receiving documentation, and a 30-calendar-day provider appeal window. If the Commissioner of Insurance finds a violation, the claim must be approved and paid with 10% per annum interest. The section applies to specified classes of third-party payment contracts delivered on or after January 1, 2027, with a carve-out for claims under active fraud investigation.
(2) A health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(d), § 514F.8D(1)(b) shall not impose on a health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c), directly or indirectly, any financial penalty, reimbursement reduction, or administrative fee, or terminate a health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c)'s participation in the health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(d), § 514F.8D(1)(b)'s network, based on the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c)'s referral to, or affiliation with, an out-of-network health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c).
(3) A health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(d), § 514F.8D(1)(b) shall not interfere with, or participate in any capacity in, a health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c)'s decisions regarding staffing and referrals, except as otherwise provided by law.
(4) A health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(d), § 514F.8D(1)(b) shall not offer, attempt to enforce, or enforce an agreement, or an amendment to an agreement, with a health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) without providing an opportunity for negotiation.
Section 514F.8D prohibits health carriers from retaliating against providers for out-of-network referrals or affiliations, from interfering in provider staffing and referral decisions, and from offering or enforcing provider agreements without an opportunity for negotiation. These are provider-protection provisions governing the carrier-provider relationship; they contain no AI-specific obligations.
(2) 5 A utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) shall not deny or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b) a request for prior authorization unless all of the following requirements are met: a. The decision to deny or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b) the request is made by either of the following: (1) A qualified reviewerQualified reviewer"Qualified reviewer" means a physician that meets all of the following requirements: (1) The physician practices in the same or a similar specialty as the health care provider that requested a prior authorization. (2) The physician has the training and expertise to treat the specific medical condition that is the subject of a request for prior authorization, including sufficient knowledge to determine whether the health care service that is the subject of the request is medically necessary or clinically appropriate. (3) The physician is employed by or contracted with the utilization review organization to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j), if the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) requesting prior authorization is a physicianPhysician"Physician" means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.Iowa Code § 514F.8A(1)(h). (2) A clinical peerClinical peer"Clinical peer" means a health care professional that meets all of the following requirements: (1) The health care professional practices in the same or similar specialty as the health care provider that requested a prior authorization. (2) The health care professional has experience managing the specific medical condition or administering the health care service that is the subject of the prior authorization request. (3) The health care professional is employed by or contracted with the utilization review organization or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(a), if the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) requesting prior authorization is not a physicianPhysician"Physician" means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.Iowa Code § 514F.8A(1)(h). b. The utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) provides the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) that requested the prior authorization all of the following: (1) A written statement that cites the specific reasons for the denial or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b), including any coverage criteria or limits, or clinical criteria, that the utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) considered or that was the basis for the denial or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b). The written statement must be signed by either of the following: (a) The qualified reviewerQualified reviewer"Qualified reviewer" means a physician that meets all of the following requirements: (1) The physician practices in the same or a similar specialty as the health care provider that requested a prior authorization. (2) The physician has the training and expertise to treat the specific medical condition that is the subject of a request for prior authorization, including sufficient knowledge to determine whether the health care service that is the subject of the request is medically necessary or clinically appropriate. (3) The physician is employed by or contracted with the utilization review organization to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j) that made the denial or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b) determination if the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) that requested prior authorization is a physicianPhysician"Physician" means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.Iowa Code § 514F.8A(1)(h). (b) The clinical peerClinical peer"Clinical peer" means a health care professional that meets all of the following requirements: (1) The health care professional practices in the same or similar specialty as the health care provider that requested a prior authorization. (2) The health care professional has experience managing the specific medical condition or administering the health care service that is the subject of the prior authorization request. (3) The health care professional is employed by or contracted with the utilization review organization or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(a) that made the denial or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b) determination if the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) that requested prior authorization is not a physicianPhysician"Physician" means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.Iowa Code § 514F.8A(1)(h). (2) A written explanation of the utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k)'s appeals process. The utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) shall also provide the written explanation to the covered personCovered person"Covered person" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(b) for whom prior authorization was requested. (3) A written attestation that is either of the following: (a) If the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) that requested prior authorization is a physicianPhysician"Physician" means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.Iowa Code § 514F.8A(1)(h), a written attestation that the qualified reviewerQualified reviewer"Qualified reviewer" means a physician that meets all of the following requirements: (1) The physician practices in the same or a similar specialty as the health care provider that requested a prior authorization. (2) The physician has the training and expertise to treat the specific medical condition that is the subject of a request for prior authorization, including sufficient knowledge to determine whether the health care service that is the subject of the request is medically necessary or clinically appropriate. (3) The physician is employed by or contracted with the utilization review organization to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j) who made the denial or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b) determination practices in the same or a similar specialty as the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c), and has the requisite training and expertise to treat the medical condition that is the subject of the request for prior authorization, including sufficient knowledge to determine whether the health care service is medically necessary or clinically appropriate. The attestation shall include the qualified reviewerQualified reviewer"Qualified reviewer" means a physician that meets all of the following requirements: (1) The physician practices in the same or a similar specialty as the health care provider that requested a prior authorization. (2) The physician has the training and expertise to treat the specific medical condition that is the subject of a request for prior authorization, including sufficient knowledge to determine whether the health care service that is the subject of the request is medically necessary or clinically appropriate. (3) The physician is employed by or contracted with the utilization review organization to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j)'s board certifications, specialty expertise, and educational background, excluding any personal identifiable information. (b) If the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) that requested prior authorization is not a physicianPhysician"Physician" means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.Iowa Code § 514F.8A(1)(h), a written attestation that the clinical peerClinical peer"Clinical peer" means a health care professional that meets all of the following requirements: (1) The health care professional practices in the same or similar specialty as the health care provider that requested a prior authorization. (2) The health care professional has experience managing the specific medical condition or administering the health care service that is the subject of the prior authorization request. (3) The health care professional is employed by or contracted with the utilization review organization or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(a) who made the denial or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b) determination practices in the same or a similar specialty as the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c), and the clinical peerClinical peer"Clinical peer" means a health care professional that meets all of the following requirements: (1) The health care professional practices in the same or similar specialty as the health care provider that requested a prior authorization. (2) The health care professional has experience managing the specific medical condition or administering the health care service that is the subject of the prior authorization request. (3) The health care professional is employed by or contracted with the utilization review organization or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(a) has experience managing the specific medical condition or administering the health care service that is the subject of the request for prior authorization. The attestation shall include the clinical peerClinical peer"Clinical peer" means a health care professional that meets all of the following requirements: (1) The health care professional practices in the same or similar specialty as the health care provider that requested a prior authorization. (2) The health care professional has experience managing the specific medical condition or administering the health care service that is the subject of the prior authorization request. (3) The health care professional is employed by or contracted with the utilization review organization or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(a)'s board certifications, specialty expertise, and educational background, excluding any personal identifiable information.
(3) 6 At the request of the requesting health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c), a utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) that denies a request for prior authorization shall, no later than seven business days after the date that the utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k) notifies the requesting health care provider of the denial, conduct a consultation either in person or remotely, as follows: a. Between the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) and a qualified reviewerQualified reviewer"Qualified reviewer" means a physician that meets all of the following requirements: (1) The physician practices in the same or a similar specialty as the health care provider that requested a prior authorization. (2) The physician has the training and expertise to treat the specific medical condition that is the subject of a request for prior authorization, including sufficient knowledge to determine whether the health care service that is the subject of the request is medically necessary or clinically appropriate. (3) The physician is employed by or contracted with the utilization review organization to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j) if the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) requesting prior authorization is a physicianPhysician"Physician" means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.Iowa Code § 514F.8A(1)(h). b. Between the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) and a clinical peerClinical peer"Clinical peer" means a health care professional that meets all of the following requirements: (1) The health care professional practices in the same or similar specialty as the health care provider that requested a prior authorization. (2) The health care professional has experience managing the specific medical condition or administering the health care service that is the subject of the prior authorization request. (3) The health care professional is employed by or contracted with the utilization review organization or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(a) if the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) requesting prior authorization is not a physicianPhysician"Physician" means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.Iowa Code § 514F.8A(1)(h).
(4) 7 a. If a utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k)'s decision to deny or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b) a request for prior authorization is appealed by the requesting health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) or covered personCovered person"Covered person" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(b), the appeal shall be conducted by either of the following: (1) A qualified reviewerQualified reviewer"Qualified reviewer" means a physician that meets all of the following requirements: (1) The physician practices in the same or a similar specialty as the health care provider that requested a prior authorization. (2) The physician has the training and expertise to treat the specific medical condition that is the subject of a request for prior authorization, including sufficient knowledge to determine whether the health care service that is the subject of the request is medically necessary or clinically appropriate. (3) The physician is employed by or contracted with the utilization review organization to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j) if the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) requesting prior authorization is a physicianPhysician"Physician" means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.Iowa Code § 514F.8A(1)(h). (2) A clinical peerClinical peer"Clinical peer" means a health care professional that meets all of the following requirements: (1) The health care professional practices in the same or similar specialty as the health care provider that requested a prior authorization. (2) The health care professional has experience managing the specific medical condition or administering the health care service that is the subject of the prior authorization request. (3) The health care professional is employed by or contracted with the utilization review organization or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(a) if the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) requesting prior authorization is not a physicianPhysician"Physician" means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.Iowa Code § 514F.8A(1)(h). b. A qualified reviewerQualified reviewer"Qualified reviewer" means a physician that meets all of the following requirements: (1) The physician practices in the same or a similar specialty as the health care provider that requested a prior authorization. (2) The physician has the training and expertise to treat the specific medical condition that is the subject of a request for prior authorization, including sufficient knowledge to determine whether the health care service that is the subject of the request is medically necessary or clinically appropriate. (3) The physician is employed by or contracted with the utilization review organization to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j) or clinical peerClinical peer"Clinical peer" means a health care professional that meets all of the following requirements: (1) The health care professional practices in the same or similar specialty as the health care provider that requested a prior authorization. (2) The health care professional has experience managing the specific medical condition or administering the health care service that is the subject of the prior authorization request. (3) The health care professional is employed by or contracted with the utilization review organization or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(a) involved in the initial denial or downgradeDowngrade"Downgrade" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.Iowa Code § 514F.8(1)(0b) determination of a request for prior authorization that is the subject of an appeal shall not conduct the appeal. c. When conducting an appeal of a request for prior authorization, the qualified reviewerQualified reviewer"Qualified reviewer" means a physician that meets all of the following requirements: (1) The physician practices in the same or a similar specialty as the health care provider that requested a prior authorization. (2) The physician has the training and expertise to treat the specific medical condition that is the subject of a request for prior authorization, including sufficient knowledge to determine whether the health care service that is the subject of the request is medically necessary or clinically appropriate. (3) The physician is employed by or contracted with the utilization review organization to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j) or clinical peerClinical peer"Clinical peer" means a health care professional that meets all of the following requirements: (1) The health care professional practices in the same or similar specialty as the health care provider that requested a prior authorization. (2) The health care professional has experience managing the specific medical condition or administering the health care service that is the subject of the prior authorization request. (3) The health care professional is employed by or contracted with the utilization review organization or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(a) shall consider the known clinical aspects of the health care services under review, including but not limited to medical records relevant to the covered personCovered person"Covered person" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(b)'s medical condition who is the subject of the health care services for which prior authorization is requested, and any relevant medical literature submitted by the health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) as part of the appeal.
Section 514F.8A establishes detailed peer-review requirements for prior authorization denials and downgrades. A utilization review organization may not deny or downgrade a prior authorization unless the decision is made by a qualified reviewer (if the requesting provider is a physician) or a clinical peer (if not), and the organization provides: (1) a signed written statement citing specific reasons including coverage or clinical criteria; (2) a written explanation of the appeals process (also provided to the covered person); and (3) a written attestation of the reviewer's qualifications. On provider request, a post-denial consultation must occur within seven business days. Appeals must be conducted by a different qualified reviewer or clinical peer who considers the patient's medical records and relevant literature. The section applies to prior authorization requests made on or after January 1, 2027.
(2) 8 A health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(d), § 514F.8D(1)(b) shall not require prior authorization for, or impose additional utilization review requirements on, a covered personCovered person"Covered person" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(b) for any of the following: a. A cancer-related screening if the cancer-related screening is recommended by the covered personCovered person"Covered person" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(b)'s health care professional based on the most recently updated national comprehensive cancer network clinical practice guidelines in oncology which are designated as category 2A or lower. b. Diagnosis and treatment of an emergency medical condition that develops or becomes evident in a covered personCovered person"Covered person" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(b) while the covered personCovered person"Covered person" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(b) is receiving inpatient care that meets inpatient care standards, if the emergency medical condition is reasonably determined by a health care professional to be a life-threatening condition unless the covered personCovered person"Covered person" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(b) receives immediate assessment and treatment.
Section 514F.8B prohibits health carriers from requiring prior authorization for two categories of care: (1) guideline-concordant cancer screenings recommended by the covered person's health care professional based on NCCN clinical practice guidelines designated category 2A or lower, and (2) diagnosis and treatment of an emergency medical condition that develops during inpatient care and is reasonably determined to be life-threatening. The section applies to health benefit plans and prior authorization requests on or after January 1, 2027.
The remedy for noncompliance with section 514F.8, 514F.8A, 514F.8B, 514F.8C, or 514F.8D shall be those remedies authorized by chapters 505 and 507B pursuant to the procedures set forth in sections 507B.6, 507B.7, and 507B.8. Upon a finding of a pattern or practice of noncompliance with sections 514F.8, 514F.8A, 514F.8B, 514F.8C, or 514F.8D, the commissioner of insurance may also suspend a utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(e), § 514F.8A(1)(k)'s authority to conduct utilization review.
Section 514F.8E establishes the enforcement mechanism for the entire bill's healthcare divisions. Remedies for noncompliance with §§ 514F.8, 514F.8A, 514F.8B, 514F.8C, and 514F.8D are those authorized by Iowa chapters 505 and 507B, following the procedures in §§ 507B.6–507B.8. Upon finding a pattern or practice of noncompliance, the Commissioner of Insurance may also suspend a utilization review organization's authority to conduct utilization review.
6A(a) A health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) shall submit all requests for prior authorization to a health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(d), § 514F.8D(1)(b) electronically using a standards-based application programming interface, or another form of electronic submission, supported by the health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(d), § 514F.8D(1)(b) that is compliant with federal interoperability regulations.
6A(b) This subsection applies to a request for prior authorization made on or after July 1, 2027.
New subsection 6A requires health care providers to submit all prior authorization requests to health carriers electronically using a standards-based API or other electronic submission method supported by the carrier that complies with federal interoperability regulations. This applies to requests made on or after July 1, 2027.
(2) 9 The department, or a managed care organizationManaged care organization"Managed care organization" means an entity acting pursuant to a contract with the department to administer the medical assistance program.Iowa Code § 249A.5(1)(b), shall not require prior authorization for, or impose additional utilization review requirements on, a recipient for any of the following: a. A cancer-related screening recommended for the recipient by the recipient's provider in accordance with the most recently updated national comprehensive cancer network clinical practice guidelines in oncology which are designated as category 2A or lower. b. The diagnosis and treatment of an emergency medical condition that develops or becomes evident in a recipient while the recipient is receiving inpatient care that meets inpatient care standards, if the emergency medical condition is reasonably determined by a provider to present a life-threatening risk unless the recipient receives immediate assessment and treatment.
Section 249A.5 extends the same prior-authorization exemption categories (guideline-concordant cancer screenings and life-threatening inpatient emergencies) to the medical assistance (Medicaid) program, binding both the department and managed care organizations. Applies to contracts and requests on or after January 1, 2027.
(1) A health care providerHealth care provider"Health care provider" means the same as defined in section 514F.8.Iowa Code § 514F.8C(1)(c) submitting a request for prior authorization to a managed care organizationManaged care organization"Managed care organization" means an entity acting pursuant to a contract with the department to administer the medical assistance program.Iowa Code § 249A.5(1)(b) shall submit the request electronically using a standards-based application programming interface, or another form of electronic submission, supported by the managed care organizationManaged care organization"Managed care organization" means an entity acting pursuant to a contract with the department to administer the medical assistance program.Iowa Code § 249A.5(1)(b), that is compliant with federal interoperability regulations.
(2) This section applies to a request for prior authorization made on or after July 1, 2027.
Section 249A.6 requires health care providers submitting prior authorization requests to Medicaid managed care organizations to do so electronically via a standards-based API or other electronic method compliant with federal interoperability regulations. Applies to requests on or after July 1, 2027.
(2) 10 The department, or a managed care organizationManaged care organization"Managed care organization" means an entity acting pursuant to a contract with the department to administer the medical assistance program.Iowa Code § 249A.5(1)(b), shall not require prior authorization for, or impose additional utilization review requirements on, an eligible child for any of the following: a. A cancer-related screening recommended for the eligible child by the eligible child's health care professional in accordance with the most recently updated national comprehensive cancer network clinical practice guidelines in oncology which are designated as category 2A or lower. b. The diagnosis and treatment of an emergency medical condition that develops or becomes evident in an eligible child while the eligible child is receiving inpatient care that meets inpatient care standards, if the emergency medical condition is reasonably determined by a health care professional to present a life-threatening risk unless the eligible child receives immediate assessment and treatment.
Section 514I.13 extends the same prior-authorization exemptions (cancer screenings and inpatient emergencies) to the Hawki (children's health insurance) program, binding both the department and managed care organizations administering Hawki. Applies to contracts and requests on or after January 1, 2027.