Ohio Revised Code Search

...n: (1) "Benzodiazepine" has the same meaning as in section 3719.01 of the Revised Code. (2) "Chronic pain" has the same meaning as in section 4731.052 of the Revised Code. (3) "Hospice care program" and "hospice patient" have the same meanings as in section 3712.01 of the Revised Code. (4) "Opioid analgesic" has the same meaning as in section 3719.01 of the Revised Code. (5) "Prescriber" has the same mean...

...led with the director of administrative services. In the case of employees of a political subdivision, the employee's authorization shall be directed to and filed with the fiscal officer of such political subdivision. In the case of employees of any institution supported in whole or in part by the state, the employee's authorization shall be directed to and filed with the fiscal officer of such institution. (C) Upon...

...Each health insuring corporation subject to this chapter may accept from governmental agencies, or from private persons, payments covering all or part of the cost of policies, contracts, and agreements entered into between the health insuring corporation and its subscribers or groups of subscribers.

...practice under sections 3901.19 to 3901.26 of the Revised Code. (F) The superintendent of insurance may adopt rules in accordance with Chapter 119. of the Revised Code as necessary to implement the provisions of this section. (G) This section does not apply to any of the following types of coverage: a policy, contract, certificate, or agreement that covers only a specified accident, accident only, credit, dental, d...

...corporation providing basic health care services shall implement a quality assurance program for use in connection with those policies, contracts, and agreements providing basic health care services. Each health insuring corporation required to implement a quality assurance program shall annually file a certificate with the superintendent of insurance certifying that its quality assurance program does all of the fol...

...gular basis, the quality of health care services provided to enrollees, based on a systematic collection, analysis, and reporting of relevant data. The health insuring corporation shall assure that a committee that includes participating physicians have the opportunity to participate in developing, implementing, and evaluating the quality assurance program and all other programs implemented by the health insuring cor...

...A health insuring corporation may present evidence of compliance with the requirements of sections 1751.73 and 1751.74 of the Revised Code by submitting certification 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 o...

...tation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health insuring corporation. (K) "Physician" means a provider who holds a license issued under Chapter 4731. of the Revised Code authorizing the practice of medicine and surgery or osteopathic medicine and surgery or a comparable license from another state. (L) "Prospective review" means utilization re...

...provides or performs utilization review services in connection with its policies, contracts, and agreements covering basic health care services and to any designee of the health insuring corporation, or to any utilization review organization that performs utilization review functions on behalf of the health insuring corporation in connection with policies, contracts, or agreements of the health insuring corpora...

...d nondelegated, for covered health care services provided, including the following: (A) Procedures to evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services; (B) The use of data sources and clinical review criteria in making decisions; (C) Mechanisms to ensure consistent application of criteria and compatible decisions; (D) Data collection processes and analytical method...

... frequency, and duration of health care services. (G) Compensation to persons providing utilization review services for the health insuring corporation shall not contain incentives, direct or indirect, for them to make inappropriate review decisions.

...res for determining whether a requested service is a service covered under the terms of an enrollee's policy, contract, or agreement, making utilization review determinations, and notifying enrollees, participating providers, and health care facilities acting on behalf of enrollees, of its determinations. (C) For prospective review determinations, a health insuring corporation shall make the determination within two...

...ection 1751.83 of the Revised Code, a health insuring corporation may afford an enrollee an opportunity for an external review under section 3922.08 or 3922.10 of the Revised Code. If an external review is conducted pursuant to this section, the health insuring corporation is not required to afford the enrollee an opportunity for any of the reviews that were disregarded pursuant to this section, including the ...

...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 enrollee. The reconsideration shall occur within three business days after the health insuring corporation's ...

...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.

... 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 car...

...bject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an enrollee than the dollar limits, deductibles, or coinsurance provisions that apply to substantially all medical and surgical benefits under the policy, contract, or agreement. (B) Benefits provided under this section shall cover, at minimum, all of the following: (1) For speech and language therapy or occupational therapy...

...nsurance under sections 3901.19 to 3901.26 of the Revised Code.

...nsurance under sections 3901.19 to 3901.26 of the Revised Code.

...e Revised Code shall be construed to create a cause of action 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.

...hall 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, restrictions, exclusions, and limitations that apply to other coverage for services performed by participating...

... 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 the Revised Code; (2) Administering immunizations in accordance with ...