What is external review?
External reviewis a second level of appeal after the insurance company's internal process. In Iowa, the Insurance Division assigns an independent review organization (IRO)—a neutral medical reviewer that does not work for the health carrier.
The program is governed by Iowa Code chapter 514J and IAC chapter 76. For eligible denials, the IRO decision is generally binding on the carrier.
General overview: Appeals roadmap.
Who can use IID review?
External review through IID generally applies when the plan denied care because:
- The service is not medically necessary or appropriate;
- The setting or level of care is wrong; or
- The treatment is experimental or investigational.
Usually does not apply to:
- Self-funded ERISA employer plans (unless the plan voluntarily participates)
- Medicaid (use MCO appeal and HHS fair hearing instead)
- Medicare (use Medicare appeals and, for Advantage, CMS / IRE processes)
- Pure contractual exclusions with no medical-judgment dispute
Deadlines & exhaustion
Exhaust internal appeals first
You must usually complete the carrier's internal appeal process before IID accepts external review (514J.106). Exceptions include when:
- You filed an internal appeal and received no decision within 30 days
- The carrier waives the internal appeal requirement
- You qualify for expedited review because time is critical for treatment
Four-month filing window
File the external review request within 4 months after the carrier denied, reduced, or terminated the service or payment (IID — External review, external review request form).
Internal appeal steps: Iowa internal appeals.
How to file with IID
- Download the form from IID — External review or the external review request (PDF).
- Attach the final adverse determination, your internal appeal request, and a signed medical release (as the form requires).
- Mail, fax, or email to the Office listed on the form (commonly 1963 Bell Avenue, Suite 100, Des Moines, IA 50315; fax 515-654-6500; email iid.marketregulation@iid.iowa.gov).
- For expedited review, call IID first at 877-955-1212 for the fastest submission instructions; your treating provider must complete the expedited certification on the form.
After IID assigns an IRO, you may send additional medical records directly to that organization. The carrier pays for the review—there is no fee to consumers for the IID process.
How long it takes
- Standard review: IID assigns an IRO; the IRO generally has up to 45 days to decide ( IID website). The overall process can take up to about 60 daysfrom IID's receipt of your request.
- Expedited review: often within 72 hours after an eligible request is received
Is the decision binding?
For covered clinical disputes, the IRO decision is generally binding on the health carrier (514J.107). If you disagree with the IRO, Iowa law may allow judicial review in district court within a short window after the decision—Iowa consumer bulletins mention 15 business days; confirm current rules with IID or an attorney if you are considering court.
If the carrier does not comply after a favorable IRO decision, see Regulator complaints and contact IID.
Medicaid & Medicare
- Medicaid: HHS appeals and fair hearings
- Medicare: Medicare basics