The bill amends the Iowa Code to establish new standards and procedures for health carriers regarding claims payment, audits, and prior authorizations. It requires health carriers to comply with specific auditing procedures and mandates timely payment or denial of clean claims within 30 days for electronic submissions and 45 days for paper claims. Health carriers are prohibited from retroactively denying claims without prior written notice and evidence of misrepresentation, fraud, or duplicate submissions. The bill introduces civil penalties for violations and allows health care providers to recover litigation costs in disputes. Additionally, it prohibits financial penalties on providers for referrals to out-of-network providers and requires negotiation opportunities for contract terms.

The legislation also sets forth new rules for prior authorizations, stating that health carriers cannot require prior authorization for certain cancer-related screenings or for the diagnosis and treatment of life-threatening conditions that arise during inpatient care. It ensures that denials or downgrades of prior authorizations are made by qualified reviewers and mandates detailed written explanations for such decisions. The provisions will apply to health benefit plans issued or renewed on or after January 1, 2027, and include measures to protect health care providers' rights in their dealings with health carriers.

Statutes affected:
Introduced: 507B.4, 507B.15, 507B.16, 507B.4A