Iowa Code-Title XIII-Chapter 514F. Utilization and Cost Control
Prior authorizations - peer review; Prior authorizations exemptions
Section 514F.8A. Prior authorizations - peer review
1. For purposes of this section, unless the context otherwise requires:
a. Clinical peer” means a health care professional that meets all of the following requirements:
(1) The health care professional practices in the same or similar specialty as the health care provider that requested a prior authorization.
(2) The health care professional has experience managing the specific medical condition or administering the health care service that is the subject of the prior authorization request.
(3) The health care professional is employed by or contracted with the utilization review organization or health carrier to which a health care provider submitted a request for prior authorization.
b. "Covered person” means the same as defined in section 514F.8.
c. "Downgrade”" means a decision by a utilization review organization to change an expedited or urgent request for prior authorization to a standard determination, or otherwise modify a health care service that is the subject of a request for prior authorization to a lower-level health care service.
d. "Health care professional” means the same as defined in section 514J.102.
e. "Health care provider“ means the same as defined in section 514F.8.
f. "Health care services” means the same as defined in means the same as defined in section 514F.8.
g. "Health carrier" means the same as defined in section 514F.8.
h. "Physician” means a doctor of medicine and surgery, or a doctor of osteopathic medicine and surgery, licensed under chapter 148.
i. “Prior authorization” means the same as defined in section 514F.8.
j. Qualified reviewer" means a physician that meets all of the following requirements:
(1) The physician practices in the same or a similar specialty as the health care provider that requested a prior authorization.
(2) The physician has the training and expertise to treat the specific medical condition that is the subject of a request for prior authorization, including sufficient knowledge to determine whether the health care service that is the subject of the request is medically necessary or clinically appropriate.
(3) The physician is employed by or contracted with the utilization review organization to which a health care provider submitted a request for prior authorization.
k. Utilization review organization” means the same as defined in section 514F.8.
2. A utilization review organization shall not deny or downgrade a request for prior authorization unless all of the following requirements are met:
(1) The physician practices in the same or a similar specialty as the health care provider that requested a prior authorization.
(2) The physician has the training and expertise to treat the specific medical condition that is the subject of a request for prior authorization, including sufficient knowledge to determine whether the health care service that is the subject of the request is medically necessary or clinically appropriate.
(3) The physician is employed by or contracted with the utilization review organization to which a health care provider submitted a request for prior authorization.
k. Utilization review organization” means the same as defined in section 514F.8.
2. A utilization review organization shall not deny or downgrade a request for prior authorization unless all of the following requirements are met:
(a) The qualified reviewer that made the denial or downgrade determination if the health care provider that requested prior authorization is a physician.
(b) The clinical peer that made the denial or downgrade determination if the health care provider that requested prior authorization is not a physician.
(2) A written explanation of the utilization review organization’s appeals process. The utilization review organization shall also provide the written explanation to the covered person for whom prior authorization was requested.
(3) A written attestation that is either of the following:
(a) If the health care provider that requested prior authorization is a physician, a written attestation that the qualified reviewer who made the denial or downgrade determination practices in the same or a similar specialty as the health care provider, and has the requisite training and expertise to treat the medical condition that is the subject of the request for prior authorization, including sufficient knowledge to determine whether the health care service is medically necessary or clinically appropriate. The attestation shall include the qualified reviewer’s board certifications, specialty expertise, and educational background, excluding any personal identifiable information.
(b) If the health care provider that requested prior authorization is not a physician, a written attestation that the clinical peer who made the denial or downgrade determination practices in the same or a similar specialty as the health care provider, and the clinical peer has experience managing the specific medical condition or administering the health care service that is the subject of the request for prior authorization. The attestation shall include the clinical peer's board certifications, specialty expertise, and educational background, excluding any personal identifiable information.
3. At the request of the requesting health care provider, a utilization review organization that denies a request for prior authorization shall, no later than seven business days after the date that the utilization review organization notifies the requesting health care provider of the denial, conduct a consultation either in person or remotely, as follows: a. Between the health care provider and a qualified reviewer if the health care provider requesting prior authorization is a physician.
b. Between the health care provider and a clinical peer if the health care provider requesting prior authorization is not a physician.
4. a. If a utilization review organization's decision to deny or downgrade a request for prior authorization is appealed by the requesting health care provider or covered person, the appeal shall be conducted by either of the following:
(1) A qualified reviewer if the health care provider requesting prior authorization is a physician.
(2) A clinical peer if the health care provider requesting prior authorization is not a physician.
b. A qualified reviewer or clinical peer involved in the initial denial or downgrade determination of a request for prior authorization that is the subject of an appeal shall not conduct the appeal.
c. When conducting an appeal of a request for prior authorization, the qualified reviewer or clinical peer shall consider the known clinical aspects of the health care services under review, including but not limited to medical records relevant to the covered person’s medical condition who is the subject of the health care services for which prior authorization is requested, and any relevant medical literature submitted by the health care provider as part of the appeal.
5. This section applies to requests for prior authorization made on or after January 1, 2027.
6. а. This section applies to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2027:
(1) Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
(2) An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
(3) An individual or group health maintenance organization contract regulated under chapter 514B.
(4) A plan established for public employees pursuant to chapter 509A.
b. This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner of insurance, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers' compensation or similar insurance, or automobile medical payment insurance.
7. The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.
Section 514F.8B. Prior authorizations exemptions.
1. For purposes of this section:
a. "Covered person“ means the same as defined in section 514F.8.
b. "Emergency medical condition” means the same as defined in 42 C.F.R. $438.114.
c. "Health benefit plan” means the same as defined in section 514J.102.
d. "Health care professional” means the same as defined in section 514J.102.
e. "Health carrier" means the same as defined in section 514F.8.
f. Prior authorization" means the same as defined in section 514F.8.
g. Utilization review“ means the same as defined in section 514F.4, subsection 3.
2. A health carrier shall not require prior authorization for, or impose additional utilization review requirements on, a covered person for any of the following:
a. A cancer-related screening if the cancer-related screening is recommended by the covered person’s health care professional based on the most recently updated national comprehensive cancer network clinical practice guidelines in oncology which are designated as category 2A or lower.
b. Diagnosis and treatment of an emergency medical condition that develops or becomes evident in a covered person while the covered person is receiving inpatient care that meets inpatient care standards, if the emergency medical condition is reasonably determined by a health care professional to be a life-threatening condition unless the covered person receives immediate assessment and treatment.
3. This section applies to all of the following:
a. Health benefit plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2027.
b. Requests for prior authorization for a cancer-related screening, if the screening is recommended by the covered person's health care professional based on the most recently updated national comprehensive cancer network clinical practice guidelines in oncology designated as category 2A or lower, and is made on or after January 1, 2027.
c. Requests for prior authorization for the diagnosis and treatment of an emergency medical condition that develops or becomes evident in a covered person while the covered person is receiving inpatient care that meets inpatient care standards, if the emergency medical condition is reasonably determined by a health care professional to be a life-threatening condition unless the covered person receives immediate assessment and treatment if the request is made on or after January 1, 2027.
4. a. This section applies to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2027:
(1) Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
(2) An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
(3) An individual or group health maintenance organization contract regulated under chapter 514B.
(4) A plan established for public employees pursuant to chapter 509A.
b. This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner of insurance, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.
5. The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.
See H.F. 2635 (2026) at https://www.legis.iowa.gov/legislation/BillBook?ga=91&ba=HF2635