Iowa

If your insurer denies your claim, you have the right to an internal appeal.^[1] This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:

• Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
• Collect information. In addition to the determination letter, collect all of the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.^[2]
• Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
• Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
• Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
•  Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

The internal appeals process should take a maximum of 30 days.^[3] The initial denial letter from your health insurer will specify the amount of time they have to respond to your appeal.^[4]

You can skip the internal appeals process and request an expedited external review in urgent situations.^[5] Your situation is urgent if waiting 30 days would seriously jeopardize your life or your ability to regain function.

During an expedited external review, an independent third party reviews your insurer’s decision.^[6] You can request an external review of the insurer’s decision in the following circumstances:

• You requested an internal appeal, but your insurer did not provide you with a decision within 30 days;^[7]
• Your insurer denied you coverage after you requested an internal appeal; or
• You your situation is urgent situation (request an expedited external review).^[8]

You can obtain the external review packet online here. This packet contains forms for both standard and expedited external reviews. Be sure to include the following information in your application:

• The name, address, telephone number, and email address of the patient;
• The name, address, telephone number, fax number, and email address of the insurance company;
• The employer’s name;
• The name and address of the treating health care provider, as well as the name, telephone number, and email address of the contact person; and
• The reason for the health insurer’s denial.

You should submit the following supporting documents with your completed external review request:

Signed medical records release form (included in packet); AND

• Any documentation not previously submitted during the internal appeal process; AND
• Final determination letter from the health insurer; OR
• Letter from health insurer stating it has waived the internal review process; OR
• A copy of the request for internal appeal and a statement that no decision has been received for 30 days; OR
• A completed request for expedited review (included in packet).^[9]

If you are requesting a standard external review, you can submit the form and copies of all supporting documents by fax to (515) 281-3059, by email to [email protected], or by mail to:

Iowa Insurance Division
330 Maple
Des Moines, IA 50319^[10]

If you are requesting an expedited external review, you must call the Iowa Insurance Division at (877) 955-1212 or (515) 281-6348 to receive instructions on the quickest way to submit the form and supporting documentation.^[11]

The external review process will take no more than 60 days.^[12] If you request an expedited external review, the process takes no longer than 72 hours after your request is received by the independent review organization.^[13]

If you are an Iowa resident, you can file a complaint with the Iowa Division of Insurance (“Division”). You can obtain the complaint form here. Your complaint should include the following information:

• The name, address, email address, and telephone number of the person filing the complaint (“applicant”);
• The name of the insured individual, if different than the applicant;
• The name of insurance company;
• Policy number, claim number, and date of loss or service;
• The details of the complaint; and
• What you consider to be a fair resolution.

You should submit the following supporting documents along with the complaint form:

• A copy of your insurance card;
• Copies of coverage denials or adverse benefit determinations from your insurer;
• Copies of any determinations made by internal and external reviewers;
• Any materials submitted with prior appeals and complaints;
• Supporting documentation from your health care provider;
• A copy of your insurance policy; and
• All responses from your insurer.^[14]

The complaint may be submitted online here, faxed to (515) 281-3059, or mailed to the following address:

Iowa Insurance Division
Market Regulation Bureau
601 Locust Street, 4^th Floor
Des Moines, IA 50309-3738^[15]

Once you file your complaint, the Division will send you an acknowledgment letter. The Division will then request a response from your health insurer and begin reviewing the information. If the Division finds that the health insurer has violated a law, the Division will request that the insurer provide you with coverage or reimburse you. The Division may also order the insurer to pay a fine.^[16] A final decision in your case may take up to six weeks.^[17]

You can contact the Iowa Division of Insurance at (877) 955-1212 or (515) 281-5705. The Division is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.