When Independent Judgment Becomes Difficult to Verify
Iowa's House File 2635, which took effect July 1, allows artificial intelligence to assist with prior authorization reviews while requiring adverse medical necessity determinations to come from a qualified clinical peer. The reviewer must also document the clinical reasoning supporting that decision. The documentation requirement is familiar. The judgment requirement is different. Rather than regulating a document or a workflow, HF 2635 regulates a cognitive process: a clinician's independent evaluation before an adverse determination is reached. That raises a practical question once the review is complete: what evidence would demonstrate that independent judgment actually occurred?
HF 2635 Regulates the Decision Before It Regulates the Record
Most administrative requirements govern something tangible that can be directly observed. A notice is sent. A form is completed. A policy is followed. HF 2635 reaches further upstream. The requirement is not that a reviewer sign an adverse determination, but that the reviewer independently evaluate the request before reaching it.
The distinction exists because the cognitive process takes place before anything is documented. Whether a clinician independently worked through the case or adopted an existing recommendation is part of how the decision was made, not part of the record created afterward. The requirement applies before the documentation ever exists.
Documentation Shows the Rationale, Not the Judgment
Once the review is complete, the remaining evidence is administrative. The record identifies the reviewer, cites the clinical criteria, and explains the determination. Those records support oversight, appeals, and compliance because they establish what decision was documented.
The reasoning process that produced the decision has already ended. Two reviewers who arrive at the same determination through different paths may leave behind the same written explanation. One independently evaluates the case before reaching a conclusion. Another reviews an AI recommendation, agrees with it, and documents the same rationale. Looking only at the completed record, those paths become difficult to distinguish.
Organizations Are Already Defining the Process Themselves
That question has already begun shaping implementation. Guidance from Paul Drey, a Des Moines healthcare attorney at Brick Gentry, encourages organizations to identify where artificial intelligence is currently used, define where human review must occur, document those workflows internally, and ensure governance reflects how these tools are actually used in practice.
The guidance extends beyond documentation itself. HF 2635 establishes who must make an adverse determination. Organizations are now being encouraged to define where human review begins, how it will be documented, and how that requirement will operate in practice.
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