"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. These standards do not apply to requests by any person 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 so stated, verification of benefits, preauthorization, and prospective or concurrent utilization review programs shall not be construed in any context as a guarantee or statement of insurance coverage of benefits for any individual under a health insurance policy.
Iowa Administrative Code rule 191-70.3(505,514F) Application.
(1) A third-party payor which provides health benefits to enrollees residing in the state of Iowa shall not conduct utilization review, either directly or indirectly, by contract with a third party that does not meet the requirements established for accreditation by the Utilization Review Accreditation Commission (URAC) or another national accreditation entity recognized and approved by the commissioner.
Any contracted agency submitting a new application or a renewal application on behalf of the third-party payor shall also submit a letter from the third-party payor authorizing it to do so.
Any material changes in the information filed in accordance with this rule shall be filed with the commissioner within 30 days of the change.
