Iowa SF2226 regulates the use of automated adjudication systems by health carriers, requiring clinical reviews before downcoding or denying claims.

Iowa SF2226 mandates that health carriers cannot use automated adjudication systems to downcode or deny claims without a clinical reviewer's individualized review. Carriers must notify providers of proposed downcodes or denials, allowing a 30-day appeal period. If a provider does not appeal, the downcode or denial must be identified in the explanation of benefits. The commissioner can impose penalties for violations, and providers can seek damages and attorney fees in civil actions. The commissioner will also establish rules for review processes, notices, appeals, and recordkeeping.

Iowa SF2226 regulates the use of automated adjudication systems by health carriers, requiring clinical reviews before downcoding or denying claims.

Iowa SF2226 mandates that health carriers cannot use automated adjudication systems to downcode or deny claims without a clinical reviewer's individualized review. Carriers must notify providers of proposed downcodes or denials, allowing a 30-day appeal period. If a provider does not appeal, the downcode or denial must be identified in the explanation of benefits. The commissioner can impose penalties for violations, and providers can seek damages and attorney fees in civil actions. The commissioner will also establish rules for review processes, notices, appeals, and recordkeeping.