Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly As used in this chapter: (A) “Adverse benefit determination” means a decision by a health plan issuer: (1) To deny, reduce, or terminate a requested health care service or payment in whole or in part, including all of the following: (a) A […]
Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly (A) A covered person may make a request for an external review of an adverse benefit determination. (B) All requests for external review shall be made in writing, including by electronic means, by the covered person to the health plan issuer within […]
Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly (A) All health plan issuers shall implement an internal appeal process under which a covered person may appeal an adverse benefit determination. This process must be in compliance with the “Patient Protection and Affordable Care Act of 2010,” Pub. L. 111-148, 124 […]
Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly (A) Except as provided in division (E) of this section, a health plan issuer is not required to grant a request for a standard external review made under section 3922.08 or 3922.10 of the Revised Code until the covered person has exhausted […]
Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly (A) A health plan issuer shall afford the opportunity for an external review by an independent review organization for an adverse benefit determination if the determination involved a medical judgment or if the decision was based on any medical information, pursuant to […]
Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly Except for when an expedited request is made under section 3922.09 or 3922.10 of the Revised Code, an independent review organization shall forward upon receipt a copy of any information received from a covered person pursuant to division (D)(1) of section 3922.05 […]
Effective: December 26, 2011 Latest Legislation: House Bill 218 – 129th General Assembly In addition to the information provided under division (D)(1)(b) of section 3922.05, division (B) of section 3922.08, division (C) of section 3922.09, and division (D) of section 3922.10 of the Revised Code, an assigned independent review organization, to the extent that such […]
Effective: December 26, 2011 Latest Legislation: House Bill 218 – 129th General Assembly (A) The provisions of this section apply only to standard reviews, which are not expedited and do not involve an experimental or investigational treatment. (B) Within five days after the receipt of a request for an external review that is complete and […]
Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly (A) A covered person may make a request for an expedited external review, except as provided in division (I) of this section: (1) After an adverse benefit determination, if both of the following apply: (a) The covered person’s treating physician certifies that […]
Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly The provisions of this section apply only to external reviews that involve an experimental or investigational treatment. (A) A covered person may request an external review of an adverse benefit determination based on the conclusion that a requested health care service is […]
Effective: January 1, 2021 Latest Legislation: House Bill 339 – 133rd General Assembly (A) The superintendent of insurance shall establish and maintain a system for receiving and reviewing requests for external review for adverse benefit determinations where the determination by the health plan issuer was based on a contractual issue and did not involve a […]
Effective: December 26, 2011 Latest Legislation: House Bill 218 – 129th General Assembly (A) An external review decision is binding on the health plan issuer except to the extent the health plan issuer has other remedies available under applicable state law, or unless the superintendent of insurance determines that, due to the facts and circumstances […]
Effective: December 26, 2011 Latest Legislation: House Bill 218 – 129th General Assembly The superintendent shall accredit independent review organizations as prescribed by this section. (A) The superintendent shall develop an application form to accredit and renew accreditation of an independent review organization. (B) An independent review organization seeking to be accredited by the superintendent, […]
Effective: January 1, 2021 Latest Legislation: House Bill 339 – 133rd General Assembly (A) To be accredited by the superintendent of insurance to conduct external reviews under section 3922.13 of the Revised Code, in addition to the requirements provided in section 3922.13 of the Revised Code and any associated rules adopted by the superintendent, an […]
Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly All clinical reviewers assigned by an independent review organization to conduct external reviews shall have the same license as the health care provider of the service in question, and shall be physicians or other appropriate health care providers who meet all of […]
Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly (A) Nothing in this chapter shall be construed to create a cause of action against any of the following: (1) An employer that provides health care benefits to employees through a health plan issuer; (2) A clinical reviewer or independent review organization […]
Effective: December 26, 2011 Latest Legislation: House Bill 218 – 129th General Assembly (A)(1) An independent review organization assigned pursuant to sections 3922.08, 3922.09, or 3922.10 of the Revised Code to conduct an external review shall maintain written records in accordance with the associated rules established by the superintendent, in the aggregate by state, and […]
Effective: December 26, 2011 Latest Legislation: House Bill 218 – 129th General Assembly The health plan issuer against which a request for a standard external review or an expedited external review is filed shall pay the cost of the external review, including the cost of any external review that is required at the direction of […]
Effective: September 6, 2012 Latest Legislation: House Bill 341 – 129th General Assembly (A) Each health plan issuer shall include a description of its external review procedures, including the superintendent’s contractual review, in, or attached to, the policy, certificate, membership booklet, or outline of coverage, or other evidence of coverage it provides to covered persons. […]
Effective: December 26, 2011 Latest Legislation: House Bill 218 – 129th General Assembly Consistent with the Rules of Evidence, a written decision or opinion prepared by an independent review organization under this chapter shall be admissible in any civil action related to the coverage decision that was the subject of the decision or opinion. The […]
