514F.4 - UTILIZATION REVIEW REQUIREMENTS.

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