Ohio Revised Code Search

...or a concurrent review determination, a health insuring corporation shall give the provider or health care facility rendering the health care service an opportunity to request in writing on behalf of the enrollee a reconsideration of an adverse determination by the reviewer making the adverse determination. The provider or health care facility may not request a reconsideration without the prior consent of the enrolle...

...A health insuring corporation may present evidence of compliance with the requirements of sections 1751.77 to 1751.82 of the Revised Code by submitting evidence to the superintendent of insurance of its accreditation by an independent, private accrediting organization, such as the national committee on quality assurance, the national quality health council, the joint commission on accreditation of health care organiz...

...Each participating provider or health care facility submitting a claim shall cooperate with the utilization review program of a health insuring corporation or utilization review organization and shall provide the health insuring corporation or its designee access to an enrollee's medical records during regular business hours, or copies of those records at a reasonable cost.

...A health insuring corporation shall annually file a certificate with the superintendent of insurance certifying its compliance with sections 1751.77 to 1751.82 of the Revised Code.

...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...

... plan, twenty hours per week; (3) For mental or behavioral health outpatient services for an enrollee under the age of fourteen that are performed by any of the following providing consultation, assessment, development, or oversight of treatment plans, thirty visits per year: (a) A licensed psychologist; (b) A licensed physician, including a psychiatrist; (c) A clinical nurse specialist or certified nurse pra...

...on 3963.01 of the Revised Code. (B) A health insuring corporation shall provide the information required in this division to all enrollees receiving coverage under an individual or group health insuring corporation policy, contract, or agreement for vision care services, vision care materials, or dental care services. The information shall be in a conspicuous format, shall be easily accessible to enrollees, and sha...

...(A) No health insuring corporation shall fail to comply with sections 1751.77 to 1751.82 of the Revised Code. (B) Whoever violates division (A) of this section is deemed to have engaged in an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

...tion against an employer that provides health care benefits to employees through a health insuring corporation.

...Sections 1751.77 to 1751.83 of the Revised Code do not apply to either of the following: (A) Coverage provided to beneficiaries enrolled in the medicare+choice program operated under Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended; (B) Coverage provided to medicaid recipients; (C) Coverage provided to participants of the children's buy-in program.

...ised Code. (B) No individual or group health insuring corporation policy, contract, or agreement shall deny coverage for the costs of any services provided to an insured through teledentistry if those services would be covered if the services were delivered other than through teledentistry. (C) The coverage that may not be excluded under division (B) of this section is subject to all terms, conditions, restrictio...

...A health insuring corporation may provide payment or reimbursement to a pharmacist for providing a health care service to a patient if both of the following are the case: (A) The pharmacist provided the health care service to the patient in accordance with Chapter 4729. of the Revised Code, including any of the following services: (1) Managing drug therapy under a consult agreement pursuant to section 4729.39 of ...

...Each health insuring corporation shall comply with the requirements of section 3959.20 of the Revised Code as they pertain to health plan issuers. As used in this section, "health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.

...re services," "subscriber," and "supplemental health care services" have the same meanings as in section 1751.01 of the Revised Code.

...A health insuring corporation shall notify a provider seeking to enter into a participation contract with the health insuring corporation of the status of the provider's application within one hundred twenty days after the health insuring corporation's receipt of the provider's completed application. That time period may be extended by a health insuring corporation if, due to extenuating circumstances, the health ins...

...pecialty health care services or supplemental health care services to disclose the health insuring corporation's aggregate maximum allowable fee table used to determine providers' fees or fee schedules.

...ipating provider's field; or if a governmental action has impaired the participating provider's ability to practice. (E) Divisions (A) to (D) of this section apply only to providers who are natural persons. (F)(1) Nothing in this section prohibits a health insuring corporation from rejecting a provider's application for participation, or from terminating a participating provider's contract, if the health insuring...

...der for the provision of basic or supplemental health care services, which health care services are within the recognized scope of practice of that category of provider.

...Every individual or group health insuring corporation policy, contract, or agreement that provides basic health care services but does not allow direct access to obstetricians or gynecologists shall permit a female enrollee to obtain covered obstetric and gynecological services from a participating obstetrician or gynecologist without obtaining a referral from the enrollee's primary care provider. No individual or g...

...(A) A health insuring corporation that does not allow direct access to all specialists shall establish and implement a procedure by which an enrollee may receive a standing referral to a specialist. The procedure shall provide for a standing referral to a specialist if a primary care provider determines in consultation with a specialist that an enrollee needs continuing care from a specialist. The referral shall be m...

...A health insuring corporation or utilization review organization that authorizes a proposed admission, treatment, or health care service by a participating provider based upon the complete and accurate submission of all necessary information relative to an eligible enrollee shall not retroactively deny this authorization if the provider renders the health care service in good faith and pursuant to the authorization a...

...f a policy, contract, or agreement of a health insuring corporation uses a restricted formulary of prescription drugs, the health insuring corporation shall do both of the following: (1) Develop such a formulary in consultation with and with the approval of a pharmacy and therapeutics committee, a majority of the members of which are physicians or advanced practice registered nurses affiliated with the health insur...

... therapies, or whether it remains experimental or investigational. The health insuring corporation's internal technology assessment process shall meet all of the following criteria: (A) Decisions are made by medical professionals, including physicians. (B) The process includes a review of relevant medical evidence, including the following, if available: (1) Peer-reviewed medical and scientific literature on the su...

... layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following: (a) Placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (b) Serious impairment to bodily functions; (c) Serious dysfunction of any bodily organ or part. (2) "Emergen...

...otherwise affect the application to any health care plan of those provisions of Title XVII or XXXIX of the Revised Code that would otherwise apply.