Iowa Insurance Division
Iowa Insurance Division
330 Maple Street
Des Moines, IA 50319-0065
(515)-281-5705 • Fax (515)-281-3059
Click below to learn of rules of the Insurance Division regulating health insurers of particular interest to physicians and their practices.
Iowa Insurance Division - Regulatory Protections (PDF 707KB)
Iowa Medicine (November/December 2005)
Prompt Pay of Clean Claims by Health Plans
Health insurers are required by Iowa law and regulations of the Insurance Division to either accept and pay or deny a clean claim within 30 days after the insurer's receipt of such claim. If payment is late, the insurer is required to automatically pay interest on the claim at the rate of 10% per annum. A "clean claim" is defined law as "a properly completed paper or electronic billing instrument containing all reasonably necessary information, that does not involve coordination of benefits for third-party liability, preexisting condition investigations, or subrogation, and that does not involve the existence of particular circumstances requiring special treatment that prevents a prompt payment from being made."
The key provisions of Iowa's prompt pay law are found in Iowa Code section 507B.4A(2). Implementing regulations of the Insurance Division are found at Iowa Administrative Code r. 191-15.32.
Claims Auditing Practices of Health Plans
Absent a reasonable basis to suspect fraud, an insurer (or agents acting on behalf of an insurer) may not audit a claim more than two years after the submission of the claim to the insurer nor can an insurer audit a claim with a billed charge of less than $25. In auditing a claim, the insurer must make a reasonable effort to ensure that the audit is performed by qualified persons and must employ coding guidelines and instructions in effect on the date the medical service was provided.
The legal basis for regulating insurers' auditing practices is found in Iowa's Insurance Trade Practices Act at Iowa Code section 507B.4(9)"o". Regulations of the Insurance Division with specific provisions are found at Iowa Administrative Code chapter 191-15.33.
External Review of Health Plan Medical Necessity Decisions
A patient, or a physician acting on behalf of the patient, can seek independent medical review of a denial of coverage by a health insurer based on medical necessity. The external review process (Xrp) can be used only after exhaustion of the insurer's internal appeals. Upon issuance of its final denial of coverage based on medical necessity, the insurer must inform the patient in writing of the patient's right to ask for an independent review of the denial. Expedited procedures exist if the patient's need for denied medical coverage is more immediate. There is a $25 filing fee which can be waived by the commissioner upon the request and a showing by the enrollee that the fee should be waived.
The legal basis for the Xrp is found in Iowa Code chapter 514J. Implementing regulations of the Insurance Division, which are key, are found at Iowa Administrative Code chapter 191-76. The law and rules are accessible by searching either http://www.legis.state.ia.us or www.iid.state.ia.us.
Consumer friendly information about the Xrp is available from the Division's web site at www.iid.state.ia.us by clicking on "Consumer information."