Iowa Code-Title XIII-Chapter 514F.8c Utilization and Cost Control. House File 2635 (2026)

See the bold text below: 

1. As used in this section, unless the context otherwise requires:

(a) *Audit" means a review, investigation, or request for additional documentation by a utilization review organization before or after issuing payment on a claim to a health care provider.

(b) "Commissioner" means the commissioner of insurance. care provider" means the same as defined in section 514F.8.

(d)  "Health carrier" means the same as defined in section 514F.8.

(e) "Utilization review organization" means the same as defined in section 514P.8.

State Medical Necessity Appeals-Deadlines; Retroactive Denial

2. (a) A utilization review organization that conducts an audit shall notify the health care provider that submitted the claim of the initiation of the audit no later than fifteen calendar days after the date the utilization review organization selects the claim for audit.

(b) A utilization review organization shall complete an audit of a claim and issue a determination on the claim to the health care provider that submitted the claim no later than forty—five calendar days after the date that the utilization review organization receives all requested documentation regarding the claim from the health care provider.

(c) A health care provider that submitted a claim that is the subject of an audit by a utilization review organization that receives an adverse determination regarding the claim may appeal the adverse determination no later than thirty calendar days after the date the health care provider receives the audit determination .

(d) A utilization review organization shall consider an appeal under paragraph and issue a final determination on the claim that is the subject of the appeal no later than thirty calendar days after the date the utilization review organization receives notice of the appeal.

(e) If, after a hearing, the commissioner finds that a utilization review organization has violated this subsection, the claim shall be approved by the utilization review organization and promptly paid, including interest at the rate of ten percent per annum.

(3) A health care provider may opt—in to receive electronic delivery of notices and audit determinations from a utilization review organization. A utilization review organization may determine the method by which a health care provider may opt—in .

(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 may adopt rules pursuant to chapter 17A to administer and enforce this section.

(6)(a) This section shall apply to an audit initiated on or after January 1, 2027.

(b) This section shall not apply to a claim that is under active fraud investigation by a state or federal authority.

See House File 2635 (2026) at https://www.legis.iowa.gov/docs/publications/LGE/91/attachments/HF2635.html