Department of
Insurance

Idaho Health Carrier External Review Act

Idaho 's external review law for health insurance claim denials will be effective for all covered plans issued or renewed on or after January 1, 2010 . Chapter 59, Title 41, Idaho Health Carrier External Review Act .

External review is only available for health claims denied for “medical necessity” or as an “investigational” service or supply. A covered person must first exhaust the insurer's internal final appeal process as described in the health insurance contract. After the insurer's final denial, the covered person may then submit a request to the Department of Insurance for an external review. The external review will be performed by an independent review organization (IRO) that is separate from the insurer and is free of charge for the covered person.

Independent Review Organizations will provide external review of denied medical claims as assigned by the Department. The IROs are required to be registered the Department and provide annual summaries of their determination of the claims assigned. Forms and application information are available here.

Insurance companies authorized to sell health insurance in the state will be required to provide external review disclosures to their covered persons at the time of the final denial of the claim.  Bulletin 09-08 describes the changes in Idaho law arising from the Idaho Health Carrier External Review Act.  Language explaining the external review process must be included in the insurance contract. Company disclosure forms and information will available here .

Consumers covered under a health benefit plan may request an external review of their denied claim if the insurance company based the denial on medical necessity or an investigational service or supply. Information, forms and instructions to request an external review will be available here.

The Department is developing the forms necessary to implement this act. Information will be posted as it becomes available.