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Appendix B EXTERNAL REVIEW REQUEST FORM SECTION 1. ELIGIBILITY FOR EXTERNAL REVIEW This External Review Request Form must be filed with the Iowa Insurance Division within four months after your health carrier denied, re
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Document Date: 2012-03-05 15:21:46
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City
Des Moines /
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IndustryTerm
Health carrier name /
health insurance policy /
health care services /
carrier Web site /
patient received emergency services /
Health carrier address /
insurance carrier /
insurance /
health carrier /
/
Organization
independent review organization /
Iowa Insurance Division /
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Position
physician /
treating physician /
authorized representative /
representative /
Governor /
board-eligible physician /
THE REASON THAT THE TREATMENT WAS EXPERIMENTAL OR INVESTIGATIONAL PHYSICIAN /
Commissioner /
legal representative /
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ProvinceOrState
Iowa /
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URL
http /
SocialTag
Medical informatics
Medical record
Health insurance
Health care provider
Medical ethics
Medical terms
Medicine
Health
Healthcare