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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 / /

ProvinceOrState

Iowa / /

URL

http /

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