514J.2 - DEFINITIONS.
514J.2 DEFINITIONS. 1. "Carrier" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, performing utilization review, 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. 2. "Commissioner" means the commissioner of insurance. 3. "Coverage decision" means a final adverse decision based on medical necessity. This definition does not include a denial of coverage for a service or treatment specifically listed in plan or evidence of coverage documents as excluded from coverage, or a denial of coverage for a service or treatment that has already been received and for which the enrollee has no financial liability. 4. "Enrollee" means an individual, or an eligible dependent, who receives health care benefits coverage through a carrier or organized delivery system. 5. "Independent review entity" means a reviewer or entity, certified by the commissioner pursuant to section 514J.6. 6. "Organized delivery system" means an organized delivery system authorized under 1993 Iowa Acts, chapter 158, and licensed by the director of public health, and performing utilization review.
Section History: Recent Form 99 Acts, ch 41, §8, 22; 2007 Acts, ch 137, §11