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Insurance Regulation and Complaints

Health Insurance Payor Complaints & Prior Authorization Enforcement

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The Iowa Medical Society (IMS) works closely with the Iowa Legislature, the Iowa Insurance Division (IID), and other stakeholders to advance fair, timely, and transparent health insurance practices for physicians and their patients. Most recently, IMS championed Prior Authorization reform legislation during the 2025 Legislative Session to promote accountability and transparency of insurers. One of the most effective tools available to regulators is data—formal complaints that document payor conduct that may violate Iowa law or administrative rules.

IMS strongly encourages physician members, clinics, hospitals, and patients to submit complaints to the Iowa Insurance Division when they experience problematic prior authorization, reimbursement, utilization review, or other health insurance payor practices.

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Why Filing Complaints Matters

Submitting a complaint:

  • Helps IID identify patterns of noncompliance by insurers and utilization review organizations (UROs)
  • Supports enforcement of Iowa insurance laws and rules
  • Strengthens future legislative and regulatory reforms
  • Creates an official record that can lead to corrective action, fines, or policy changes

Even if an issue is eventually resolved, filing a complaint is still important to ensure regulators understand the scope and frequency of the problem.

Who May File a Complaint

The following parties may submit complaints to the Iowa Insurance Division:

  • Physicians and other health care professionals
  • Physician practices and clinics
  • Hospitals and health systems
  • Patients or covered individuals
  • Authorized representatives acting on behalf of a patient or provider

Complaints may involve commercial health insurers, HMOs, and utilization review organizations operating in Iowa.

Laws and Rules Commonly Implicated

Many complaints involve potential violations of:

These provisions establish requirements for prior authorization timelines, notice obligations, continuity of care protections, appeal rights, and reimbursement practices.

How to File an Insurance Complaint

Step 1: Determine Whether the Issue Is Eligible

Confirm that the issue involves a health insurer or utilization review organization subject to Iowa regulation and relates to prior authorization, utilization review, reimbursement, coverage determinations, or claims handling.

Step 2: Gather Supporting Information

Helpful documentation may include:

  • Prior authorization requests and responses
  • Explanation of Benefits (EOBs)
  • Denial or partial denial letters
  • Medical necessity determinations
  • Correspondence with the insurer or URO
  • Dates of submission, response, and services rendered
Step 3: Submit the Complaint Online

File a complaint directly with the Iowa Insurance Division using its online complaint portal.

SUBMIT A COMPLAINT
Step 4: IID Review Period

The Iowa Insurance Division generally reviews complaints within 30–45 days, though timelines may vary depending on complexity.

Step 5: Review the Division’s Response

IID may:

  • Request additional information
  • Require the insurer to respond
  • Provide guidance on next steps or appeal options
  • Take enforcement or corrective action when appropriate

Additional information on the Steps to File an Insurance Complaint can be found on IID’s website here.

Conduct Subject to Enforcement by the Iowa Insurance Division

The following examples illustrate conduct that may be subject to IID enforcement. This list is not exhaustive.

Prior Authorization & Utilization Review Violations
  • Failure by a utilization review organization (URO) to issue determinations for:
    • Urgent prior authorization requests within 48 hours
    • Non-urgent prior authorization requests within 10 calendar days
  • Failure by a URO to acknowledge receipt of a prior authorization request within 24 hours
  • Revoking, limiting, conditioning, or restricting a prior authorization after services have been rendered pursuant to that authorization
  • Retroactively changing prior authorization requirements, clinical criteria, or documentation standards in a way that makes compliance impracticable or impossible and results in claim denial
  • Applying prior authorization requirements inconsistently or selectively across similarly situated providers
  • Failure to use qualified, appropriately licensed clinicians to make utilization review or medical necessity determinations
  • Denials based on criteria that are not evidence-based or that are inconsistent with generally accepted standards of medical practice
Reimbursement & Claims Processing Issues
  • Denial or reduction of payment for services that were properly authorized and rendered
  • Failure to pay clean claims within required timeframes
  • Downcoding, bundling, or recoupment without adequate explanation or justification
  • Requiring unnecessary documentation after services are rendered as a condition of payment
  • Imposing administrative barriers that delay or prevent payment despite compliance with plan requirements
Continuity of Care & Prescription Drug Protections
  • Limiting or excluding coverage of a prescription drug for a covered person who is medically stable on the drug when:
    • The drug was previously approved by the carrier
    • The drug was prescribed within the previous six months
    • The individual remains enrolled in the health benefit plan
  • Forcing non-medical switching that disrupts continuity of care
Appeals, Notice, and Transparency Failures
  • Failure to provide timely, clear, and specific notice of an adverse determination
  • Failure to include the clinical rationale or criteria relied upon for a denial
  • Failure to inform providers or patients of appeal rights or required appeal procedures
  • Unreasonable delays in internal appeals or external review processes
Other Potentially Enforceable Conduct
  • Noncompliance with utilization review certification or reporting requirements
  • Failure to follow Iowa-specific utilization review standards despite operating in the state
  • Systemic practices that discourage or obstruct lawful appeals
  • Any other conduct that violates of Iowa Code Chapter 514F or Iowa Administrative Code rule 191-70

Tips for a Strong Complaint

  • Be specific and factual - include dates and timelines
  • Attach relevant documentation whenever possible
  • Focus on how the conduct violates required processes or protections
  • File complaints even if the issue was later resolved

IMS Support

IMS uses complaint data to inform advocacy efforts, regulatory discussions, and legislative initiatives aimed at reducing administrative burden and protecting patient access to care.

If you have questions about whether an issue may be appropriate for a complaint or wish to share trends you are seeing in your practice, IMS encourages you to contact IMS Staff directly.

More Resources

This page is intended for informational purposes and does not constitute legal advice.

Contact

Seth Brown - Director of Government Relations

Charlie Murphy - Policy Analyst

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