3922.08 Provisions applicable to standard reviews; Timing;.

(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 valid, the health plan issuer shall provide to the assigned independent review organization all documents and information considered in making the adverse benefit determination.

(C) An external review shall not be delayed due to failure on the part of the health plan issuer to provide the information required under division (B) of this section.

(D)

(1) An independent review organization may reverse an adverse benefit determination if the information required under division (B) of this section is not provided in the allotted time. The independent review organization may also grant a request from the health plan issuer for more time to provide the required information.

(2) If an adverse benefit determination is reversed under division (D)(1) of this section, the independent review organization shall notify, within one business day of making the decision, the covered person, the health plan issuer, and the superintendent of insurance.

Added by 129th General AssemblyFile No.48, HB 218, §1, eff. 12/26/2011.