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.
"DowngradeDowngrade"Downgrade" means a decision by a health carrier or 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)" means a decision by a health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) or utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) 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.
Section 1 adds a new defined term to existing section 514F.8: "Downgrade" captures decisions by health carriers or utilization review organizations to convert expedited or urgent prior authorization requests into standard determinations, or to modify the requested service to a lower-level service. This definition is referenced throughout Division I.
(2A) 1 A utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) may use an artificial intelligence-based algorithm 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.8A(1)(k) shall not use an artificial intelligence-based algorithm 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.8A(1)(k)'s decision to deny, delay, or downgradeDowngrade"Downgrade" means a decision by a health carrier or 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.
Section 2 adds a new subsection to existing section 514F.8 permitting utilization review organizations to use AI-based algorithms for initial review of prior authorization requests, but prohibiting AI as the sole basis for decisions to deny, delay, or downgrade requests based on medical necessity. This is the bill's core AI-specific provision and directly parallels HC-01.1 obligations seen in other states' healthcare AI legislation.
(1)(a)–(k) 1. For purposes of this section: 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)" 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 organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) or health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) to which a health care provider submitted a request for prior authorization. b. "Covered person" means the same as defined in section 514F.8. c. "DowngradeDowngrade"Downgrade" means a decision by a health carrier or 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)" means a decision by a health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) or utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) 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. d. "Health care professional" means the same as defined in section 514J.102. e. "Health care provider" means the same as defined in section 514F.8. f. "Health care services" means the same as defined in section 514F.8. g. "Health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g)" means the same as defined in section 514F.8. h. "PhysicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery licensed under chapter 148.Iowa Code § 514F.8A(1)(h)" means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery licensed under chapter 148. i. "Prior authorization" means the same as defined in section 514F.8. j. "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 or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j)" means a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery licensed under chapter 148.Iowa Code § 514F.8A(1)(h) that meets all of the following requirements: (1) The physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery licensed under chapter 148.Iowa Code § 514F.8A(1)(h) practices in the same or a similar specialty as the health care provider that requested a prior authorization. (2) The physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery licensed under chapter 148.Iowa Code § 514F.8A(1)(h) 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 physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery licensed under chapter 148.Iowa Code § 514F.8A(1)(h) is employed by or contracted with the utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) or health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) to which a health care provider submitted a request for prior authorization. k. "Utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k)" means the same as defined in section 514F.8.
(2) 2 2. A utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) shall not deny or downgradeDowngrade"Downgrade" means a decision by a health carrier or 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 health carrier or 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 or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j), if the health care provider requesting prior authorization is a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed 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 provider requesting prior authorization is not a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed 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.8A(1)(k) provides the health care provider 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 health carrier or 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.8A(1)(k) considered or that was the basis for the denial or downgradeDowngrade"Downgrade" means a decision by a health carrier or 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 shall 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 or health carrier 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 health carrier or 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 provider that requested prior authorization is a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed 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 health carrier or 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 provider that requested prior authorization is not a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed 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.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.8A(1)(k) shall also provide the written explanation to the covered person for whom prior authorization was requested. (3) A written attestation that is either of the following: (a) If the health care provider that requested prior authorization is a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed 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 or health carrier 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 health carrier or 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 provider, 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 or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j)'s name, national provider identifier, board certifications, specialty expertise, and educational background. (b) If the health care provider that requested prior authorization is not a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed 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 health carrier or 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 provider, 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 name, national provider identifier, board certifications, specialty expertise, and educational background.
(3) 3 3. A utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 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.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 provider 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 or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j), if the health care provider requesting prior authorization is a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery licensed under chapter 148.Iowa Code § 514F.8A(1)(h). b. Between the health care provider 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 provider requesting prior authorization is not a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery licensed under chapter 148.Iowa Code § 514F.8A(1)(h).
(4) 4 4. a. If a utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k)'s decision to deny or downgradeDowngrade"Downgrade" means a decision by a health carrier or 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 provider or covered person, 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 or health carrier to which a health care provider submitted a request for prior authorization.Iowa Code § 514F.8A(1)(j), if the health care provider requesting prior authorization is a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed 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 provider requesting prior authorization is not a physicianPhysician"Physician" means a licensed doctor of medicine and surgery or a licensed 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 or health carrier 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 health carrier or 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 or health carrier 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 person's medical condition that is the subject of the health care services for which prior authorization is requested, and any relevant medical literature submitted by the health care provider as part of the appeal.
(5) 5. The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.
Section 3 creates new section 514F.8A, the bill's most substantive provision. It establishes definitions for clinical peer, qualified reviewer, and other terms, then imposes four major obligations on utilization review organizations: (1) denials or downgrades must be made by a qualified reviewer (if requesting provider is a physician) or clinical peer (if not); (2) the URO must provide the requesting provider a written statement of reasons, an explanation of the appeals process, and a written attestation of the reviewer's qualifications; (3) within seven business days of a denial, the URO must conduct a consultation between the provider and the reviewer; (4) appeals must be conducted by a different qualified reviewer or clinical peer who considers the known clinical aspects of the case.
(1)–(4) 1. For purposes of this section: a. "Covered person" means the same as defined in section 514F.8. b. "Health benefit plan" means the same as defined in section 514J.102. c. "Health care professional" means the same as defined in section 514J.102. d. "Health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g)" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance company offering sickness and accident plans, a health maintenance organization, a nonprofit health service corporation, a plan established pursuant to chapter 509A for public employees, or any other entity providing a plan of health insurance, health care benefits, or health care services. "Health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g)" includes the following: (1) The medical assistance program under chapter 249A and the healthy and well kids in Iowa (Hawki) program under chapter 514I. (2) A managed care organization acting pursuant to a contract with the department of health and human services to administer the medical assistance program under chapter 249A, or the healthy and well kids in Iowa (Hawki) program under chapter 514I. e. "Prior authorization" means the same as defined in section 514F.8. f. "Utilization review" means the same as defined in section 514F.4, subsection 3.
(2) 5 2. A health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) shall not require prior authorization for, or impose additional utilization review requirements on, a covered person for a cancer-related screening if the screening is recommended by the covered person's health care professional based on the most recently updated national comprehensive cancer network clinical practice guidelines in oncology.
(3)–(4) 3. The director of health and human services shall adopt rules pursuant to chapter 17A to administer this section, including but not limited to rules relating to all of the following: a. The medical assistance program under chapter 249A and the healthy and well kids in Iowa (Hawki) program under chapter 514I. b. A managed care organization acting pursuant to a contract with the department of health and human services to administer the medical assistance program under chapter 249A, or the healthy and well kids in Iowa (Hawki) program under chapter 514I. 4. The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section, except as otherwise provided in subsection 3.
Section 5 creates new section 514F.8B, prohibiting health carriers from requiring prior authorization for, or imposing additional utilization review requirements on, cancer-related screenings recommended by a covered person's health care professional based on the most recently updated National Comprehensive Cancer Network clinical practice guidelines in oncology. This is not an AI-specific provision but a substantive prior authorization exemption that restricts the contexts in which AI-assisted utilization review could apply.
(1)–(3) 1. For purposes of this section: a. "Covered person" means the same as defined in section 514F.8. b. "Health benefit plan" means the same as defined in section 514J.102. c. "Health care professional" means the same as defined in section 514J.102. d. "Health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g)" means the same as defined in section 514F.8. e. "Prior authorization" means the same as defined in section 514F.8. f. "Utilization review" means the same as defined in section 514F.4, subsection 3.
(2) 6 2. A health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) shall not require prior authorization for, or impose additional utilization review requirements on, a covered person for diagnosis and treatment of a health condition that develops or becomes evident in a covered person while the covered person is receiving treatment at an inpatient facility, and the health condition is reasonably determined by a health care professional to be a life-threatening condition unless the covered person receives immediate assessment and treatment.
(3) 3. The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.
Section 7 creates new section 514F.8C, prohibiting health carriers from requiring prior authorization for diagnosis and treatment of health conditions that develop or become evident while a covered person is receiving inpatient treatment, where a health care professional reasonably determines the condition is life-threatening unless the patient receives immediate assessment and treatment. Like the cancer screening exemption, this removes a category of decisions from the prior authorization (and thus AI review) process entirely.
(1) 1. For purposes of this section: a. "AuditAudit"Audit" means a review, investigation, or request for additional documentation by a health carrier or utilization review organization on behalf of the health carrier prior to or after issuing payment on a claim to a health care provider.Iowa Code § 514F.10(1)(a)" means a review, investigation, or request for additional documentation by a health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) or utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) on behalf of the health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) prior to or after issuing payment on a claim to a health care provider. b. "Health care provider" means the same as defined in section 514F.8. c. "Health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g)" means the same as defined in section 514F.8. d. "Utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k)" means the same as defined in section 514F.8.
(2) 7 2. A health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) or utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) that conducts an auditAudit"Audit" means a review, investigation, or request for additional documentation by a health carrier or utilization review organization on behalf of the health carrier prior to or after issuing payment on a claim to a health care provider.Iowa Code § 514F.10(1)(a) shall notify the health care provider that submitted the claim of the initiation of the auditAudit"Audit" means a review, investigation, or request for additional documentation by a health carrier or utilization review organization on behalf of the health carrier prior to or after issuing payment on a claim to a health care provider.Iowa Code § 514F.10(1)(a) no later than fifteen calendar days after the date the health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) selects the claim for auditAudit"Audit" means a review, investigation, or request for additional documentation by a health carrier or utilization review organization on behalf of the health carrier prior to or after issuing payment on a claim to a health care provider.Iowa Code § 514F.10(1)(a).
(3) 8 3. A health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) or utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) shall complete an audit of a claim and issue a determination on the claim to the health care provider 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.8A(1)(k) receives all requested documentation regarding the claim from the health care provider.
(4) 4. A health care provider that submitted a claim that is the subject of an auditAudit"Audit" means a review, investigation, or request for additional documentation by a health carrier or utilization review organization on behalf of the health carrier prior to or after issuing payment on a claim to a health care provider.Iowa Code § 514F.10(1)(a) by a health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) or utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k), and 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 provider receives the auditAudit"Audit" means a review, investigation, or request for additional documentation by a health carrier or utilization review organization on behalf of the health carrier prior to or after issuing payment on a claim to a health care provider.Iowa Code § 514F.10(1)(a) determination.
(5) 9 5. A health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) or utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) shall consider an appeal under subsection 4, and issue a final determination on the claim that is the subject of the appeal, no later than fourteen calendar days after that date the health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) or utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) receives notice of the appeal.
(6) 6. If a health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) or utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) violates this section, the claim shall be automatically approved by the health carrierHealth carrier"Health carrier" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(g) or utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in section 514F.8.Iowa Code § 514F.8A(1)(k) and promptly paid pursuant to section 507B.4A, subsection 2.
(7) 7. The commissioner of insurance may adopt rules pursuant to chapter 17A to administer and enforce this section.
Section 9 creates new section 514F.10, imposing procedural requirements on health carriers and utilization review organizations conducting audits of claims. The section requires: 15-calendar-day notice to providers after a claim is selected for audit; 45-calendar-day completion and determination deadline; a 30-day provider appeal window; 14-day appeal determination deadline; and automatic claim approval with prompt payment as the remedy for violations. While not AI-specific, these audit procedures constrain the operational context in which AI-assisted claim review could function.
This division of this Act applies to all of the following: 1. Requests for prior authorization made before January 1, 2027, if the request has not been finally determined on or before that date. 2. Requests for prior authorization made on or after January 1, 2027.
Section 4 specifies that Division I (AI restrictions and peer review requirements) applies to prior authorization requests made before January 1, 2027, that have not been finally determined by that date, and to all requests made on or after January 1, 2027.
This division of this Act applies to all of the following: 1. Health benefit plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2027. 2. Requests for prior authorization for a cancer-related screening if the screening is recommended by the covered person's health care professional based on the most recently updated national comprehensive cancer network clinical practice guidelines in oncology, the request is made before January 1, 2027, and the request has not been finally determined on or before that date. 3. Requests for prior authorization for a cancer-related screening, if the screening is recommended by the covered person's health care professional based on the most recently updated national comprehensive cancer network clinical practice guidelines in oncology, made on or after January 1, 2027.
Section 6 specifies that Division II (cancer screening exemptions) applies to health benefit plans delivered, issued, continued, or renewed on or after January 1, 2027, and to qualifying cancer screening requests pending or made on or after that date.
This division of this Act applies to all of the following: 1. Health benefit plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2027. 2. Requests for prior authorization for diagnosis and treatment of a health condition that develops or becomes evident in a covered person while the covered person is receiving treatment at an inpatient facility if the health condition is reasonably determined by a health care professional to be a life-threatening condition unless the covered person receives immediate assessment and treatment, the request is made before January 1, 2027, and the request has not been finally determined on or before that date.
Section 8 specifies that Division III (life-threatening condition exemptions) applies to health benefit plans delivered, issued, continued, or renewed on or after January 1, 2027, and to qualifying requests pending or made on or after that date.
This division of this Act applies to auditsAudit"Audit" means a review, investigation, or request for additional documentation by a health carrier or utilization review organization on behalf of the health carrier prior to or after issuing payment on a claim to a health care provider.Iowa Code § 514F.10(1)(a) initiated on or after January 1, 2027.
Section 10 specifies that Division IV (prepayment audit procedures) applies to audits initiated on or after January 1, 2027.