A health insuring corporation shall establish and maintain an internal review system that has been approved by the superintendent of insurance. The system shall provide for review by a clinical peer and include adequate and reasonable procedures for review and resolution of appeals from enrollees concerning adverse determinations made under section 1751.81 of the Revised Code, including procedures for verifying and reviewing appeals from enrollees whose medical conditions require expedited review.
A health insuring corporation shall consider and provide a written response to each request for an internal review not later than thirty days after receipt of the request, except that if the seriousness of the enrollee's medical condition requires an expedited review, the health insuring corporation shall provide the written response not later than seven days after receipt of the request or in accordance with applicable preemptive federal laws or regulations. The response shall state the reason for the health insuring corporation's decision, inform the enrollee of the right to pursue a further review, and explain the procedures for initiating the review, including the time frames within which the enrollee must request the review, as specified in section 3922.02 of the Revised Code. Failure by a health insuring corporation to provide a written response within the time frames specified under this section shall be deemed a denial by the health insuring corporation for purposes of requesting an external review under Chapter 3922. of the Revised Code.
If the health insuring corporation has denied, reduced, or terminated coverage for a health care service on the grounds that the service is not a service covered under the terms of the enrollee's policy, contract, or agreement, the response shall inform the enrollee of the right to request a review by the superintendent of insurance under Chapter 3922. of the Revised Code. If the health insuring corporation has denied, reduced, or terminated coverage for a health care service on the grounds that the service is not medically necessary, the response shall inform the enrollee of the right to request an external review under Chapter 3922. of the Revised Code.
The health insuring corporation shall make available to the superintendent for inspection copies of all documents in the health insuring corporation's possession related to reviews conducted pursuant to this section, including medical records related to those reviews, and of responses, for three years following completion of the review.
Amended by 129th General AssemblyFile No.48, HB 218, §1, eff. 12/26/2011.
Effective Date: 05-01-2000 .