Utilization Review Licensing in Iowa

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Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Iowa. For assistance with licensing, please contact us to learn about our software and managed license services.

Iowa Independent Review Organization Certification

Type of Review:

Medical Utilization Review

Agency:Iowa Insurance Division

Initial Registration

Form:

Independent Review Organization Application

Agency Fee:

$0

Required Attachments:
  • Names and titles of all directors, officers, and executives
  • List of all clinical reviewers to be assigned by your IRO by name, general certification,
    and specialty or subspecialty certification

Registration Renewal

Form:

Independent Review Organization Application (Renewal)

Agency Fee:

$0

Due:

Biennially

Iowa Utilization Reviewer Statement of Certification

Type of Review:

Medical Utilization Review

Agency:Iowa Insurance Division
Law:

IAC § 514F.4

Automatic Exemption

Exemption Eligible Organizations:

Entities that perform utilization review solely under contract with
the federal government for review of patients eligible for services under:

  • Title XVIII (Medicare) of the federal Social Security Act;
  • The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); or
  • Any other federal employee health benefit plan
Law:

IAC § 70.3(3)

Initial Registration

Filing Method:

Online

Agency Fee:

$0

Required Attachments:
  • Proof of current Health Utilization Management or other utilization review accreditation from URAC or NCQA

Registration Renewal

Filing Method:

Online

Agency Fee:

$0

Due:

Annually by March 1.

Iowa Resources

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Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

Revised February 05, 2021. Complete data last reviewed February 05, 2021.
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