Ohio Revised Code Search

...s any policyholder, subscriber, member, employee, or other person who is eligible for benefits under a benefits contract. (B) "Benefits contract" means a sickness and accident insurance policy providing hospital, surgical, or medical expense coverage, or a health insuring corporation contract or other policy or agreement under which a third-party payer agrees to reimburse for covered health care or dental services r...

... employer whose premium for coverage of employees under a benefits contract has not been received by the third-party payer. (E) Compliance with the provisions of division (B)(3) of this section shall be determined separately from compliance with the provisions of divisions (B)(1) and (2) of this section. (F) A third-party payer shall transmit electronically any payment with respect to claims that the third-party ...

...Beginning six months after the date specified in section 262 of the "Health Insurance Portability and Accountability Act of 1996," 110 Stat. 2027, 42 U.S.C.A. 1320d-4, on which a third-party payer is initially required to comply with a standard or implementation specification for the electronic exchange of health information, as adopted or established by the United States secretary of health and human services pursua...

...(A) A provider and a third-party payer may do either of the following: (1) Enter into a contractual agreement under which time periods shorter than those set forth in section 3901.381 of the Revised Code are applicable to the third-party payer in paying a claim for any amount due for health care services rendered by the provider; (2) Enter into a contractual agreement under which the timing of payments by the thir...

...(A) Subject to division (B) of this section, a third-party payer that requires timely submission of claims for payment for health care services shall process a claim that is not submitted in a timely manner if a claim for the same services was initially submitted to a different third-party payer or state or federal program that offers health care benefits and that payer or program has determined that it is not respon...

...A third-party payer shall not do either of the following: (A) Engage in any business practice that unfairly or unnecessarily delays the processing of a claim or the payment of any amount due for health care services rendered by a provider to a beneficiary; (B) Refuse to process or pay within the time periods specified in section 3901.381 of the Revised Code a claim submitted by a provider on the grounds the benefic...

...(A) Notwithstanding section 1751.13 or division (I)(2) of section 3923.04 of the Revised Code, a reimbursement contract entered into or renewed on or after June 29, 1988, between a third-party payer and a hospital shall provide that reimbursement for any service provided by a hospital pursuant to a reimbursement contract and covered under a benefits contract shall be made directly to the hospital. (B) If the third-p...

...(A) When a provider or beneficiary submits a duplicative claim for payment for health care services before the time periods specified in section 3901.381 of the Revised Code have elapsed for the original claim submitted, the third-party payer may deny the duplicative claim. Denials of claims determined to be duplicative by the department of insurance shall not be considered by the department in a market conduct exami...

...(A) A payment made by a third-party payer to a provider in accordance with sections 3901.381 to 3901.386 of the Revised Code shall be considered final two years after payment is made. After that date, the amount of the payment is not subject to adjustment, except in the case of fraud by the provider. (B) A third-party payer may recover the amount of any part of a payment that the third-party payer determines to be a...

...(A) Any third-party payer that fails to comply with section 3901.381 of the Revised Code, or any contractual payment arrangement entered into under section 3901.383 of the Revised Code, shall pay interest in accordance with this section. (B) Interest shall be computed based upon the number of days that have elapsed between the date payment is due in accordance with section 3901.381 of the Revised Code or the contrac...

...(A) A provider or beneficiary aggrieved with respect to any act of a third-party payer that the provider or beneficiary believes to be a violation of sections 3901.381 to 3901.388 of the Revised Code may file a written complaint with the superintendent of insurance regarding the violation. (B) A third-party payer shall not retaliate against a provider or beneficiary who files a complaint under division (A) of this ...

...(A) No third-party payer shall fail to comply with sections 3901.381 and 3901.384 to 3901.3810 of the Revised Code. (B) The superintendent of insurance may require third-party payers to submit reports of their compliance with division (A) of this section. If reports are required, the superintendent shall prescribe the content, format, and frequency of the reports in consultation with third-party payers. The superint...

...(A) If, after completion of an examination involving information collected from a six-month period, the superintendent finds that a third-party payer has committed a series of violations that, taken together, constitutes a consistent pattern or practice of violating division (A) of section 3901.3811 of the Revised Code, the superintendent may impose on the third-party payer any of the administrative remedies specifie...

...The superintendent of insurance may adopt rules as the superintendent considers necessary to carry out the purposes of section 3901.38 and sections 3901.381 to 3901.3812 of the Revised Code. The rules shall be adopted in accordance with Chapter 119. of the Revised Code.

...Sections 3901.38 and 3901.381 to 3901.3813 of the Revised Code do not apply to the following: (A) Policies offering coverage that is regulated under Chapters 3935. and 3937. of the Revised Code; (B) An employer's self-insurance plan and any of its administrators, as defined in section 3959.01 of the Revised Code, to the extent that federal law supersedes, preempts, prohibits, or otherwise precludes the applicatio...

...(A) As used in this section: (1) "Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code, except that the term also includes any vendor contracted by a health plan issuer, as defined in that section. (2) "Health care provider" has the same meaning as in section 3701.74 of the Revised Code. (3) "Credit card" means a single-use or virtual payment card provided in an electronic, digita...

...No insurance company, health insuring corporation, or self-insurance plan authorized to do business in this state shall include or provide in its policies or subscriber agreements for benefit payments or reimbursement for services in any hospital which is not licensed under Chapter 3722. of the Revised Code. No hospital located in this state shall charge any insurance company, health insuring corporation, federal, st...

...and other mandated materials under the "Employee Retirement Income Security Act of 1974," 88 Stat. 829, 29 U.S.C. 1001, as amended, and any regulation adopted thereunder. (I) If the consent of an insured to receive certain notices, documents, or information in an electronic form is on file with an insurer before September 4, 2014, if the consent was not accompanied by the details of the automated transaction descri...

...ough medicare, medicaid, or the federal employees benefit program; (g) Any coverage issued under Chapter 55 of Title 10 of the United States Code and any coverage issued as a supplement to that coverage. (2) "Health plan issuer" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the superintendent of insurance, that contracts, or offers to contract, to provide...

... actual malice, members, delegates, and employees of the national association of insurance commissioners, its authorized committees, subcommittees, and task forces, and all others charged with the responsibility of collecting, reviewing, analyzing, and disseminating the information developed from the filing of the annual statement convention blanks shall be acting as agents of the superintendent under the authority o...

..., the superintendent shall not prohibit public inspection of such records that pertain to an insurance fraud investigation after the expiration of all federal and state statutes of limitations applicable to the particular offense to which the papers, documents, reports, and evidence relate. (C) All documents, reports, and evidence in the possession of the superintendent that do not pertain to such an insurance frau...

...(A) As used in sections 3901.45 and 3901.46 of the Revised Code: (1) "AIDS," "HIV," "AIDS-related condition," and "HIV test" have the same meanings as in section 3701.24 of the Revised Code. (2) "Insurer" means any person authorized to engage in the business of life or sickness and accident insurance under Title XXXIX of the Revised Code or any person or governmental entity providing health services coverage for ...

...As used in this section, "membership organization" means a fraternal or other association or group of individuals involved in the same occupation, activity, or interest that is organized and maintained in good faith for purposes other than to obtain insurance and is not organized or maintained for the purpose of engaging in activities for gain or profit. (A) In underwriting an individual policy of life or sickness a...

...(A) As used in this section: (1) "Insurer" means any insurer authorized to write life or sickness and accident insurance in this state under Title XXXIX of the Revised Code. (2) "Insolvent insurer" means any of the following: (a) Farm and ranch life insurance company, domiciled in the state of Kansas; (b) First transcontinental life insurance corporation, domiciled in the state of Wisconsin; (c) Lumbermen's life...

...The original work papers of a certified public accountant performing an audit of an insurance company or health insuring corporation doing business in this state that is required by rule or by any section of the Revised Code to file an audited financial report with the superintendent of insurance shall remain the property of the certified public accountant. Any copies of these work papers voluntarily given to the sup...

...(A) A medical assistance recipient's enrollment in a medical assistance program gives an automatic right of recovery to the department of medicaid and a county department of job and family services against the liability of a third party for the cost of medical assistance paid on behalf of the recipient. When an action or claim is brought against a third party by a medical assistance recipient, any payment, settlement...

...In addition to the requirement of division (C) of section 5160.37 of the Revised Code to cooperate with the department of medicaid and county department of job and family services, a medical assistance recipient and the recipient's attorney, if any, shall cooperate with each medical provider of the recipient. Cooperation with a medical provider shall consist of disclosing to the provider all information the rec...

...(A) The application for, or enrollment in, a medical assistance program constitutes an automatic assignment of rights specified in division (B) of this section to the department of medicaid. This assignment includes the rights of the medical assistance recipient and also the rights of any other member of the assistance group for whom the recipient can legally make an assignment. (B) Pursuant to this section, ...

...e information is confidential and not a public record under section 149.43 of the Revised Code. (2) The release of information to the department is not to be considered a violation of any right of confidentiality or contract that the third party may have with covered persons including, but not limited to, contractees, beneficiaries, heirs, assignees, and subscribers. (3) The third party is immune from any liab...

...(A) As used in this section, "business day" means any day of the week excluding Saturday, Sunday, and a legal holiday, as defined in section 1.14 of the Revised Code. (B) Subject to divisions (C) and (D) of this section, a third party shall do all of the following: (1) Accept the department of medicaid's right of recovery under section 5160.37 of the Revised Code and the assignment of rights to the department t...

...(A) A payment made by a third party under division (B)(5) of section 5160.40 of the Revised Code on a claim for payment of a medical item or service provided to a medical assistance recipient is final on the date that is two years after the payment was made to the department of medicaid or the applicable medicaid managed care organization. After a claim is final, the claim is subject to adjustment only if an action f...

...No third party shall consider whether an individual is eligible for or enrolled in a medical assistance program when either of the following applies: (A) The individual seeks to obtain a policy or enroll in a plan or program operated or administered by the third party; (B) The individual, or a person or governmental entity on the individual's behalf, seeks payment for a medical item or service provided to the...

...(A) If a third party violates section 5160.39, 5160.40, or 5160.41 of the Revised Code, a governmental entity that is responsible for issuing a license, certificate of authority, registration, or approval that authorizes the third party to do business in this state may impose a fine against the third party or deny, revoke, or terminate the third party's license, certificate, registration, or approval to do busi...

...(A) The medicaid director may adopt rules under section 5160.02 of the Revised Code to implement sections 5160.35 to 5160.43 of the Revised Code, including rules that specify what constitutes cooperating with efforts to obtain support or payments, or medical assistance payments, and when cooperation may be waived. (B) The department shall adopt rules under section 5160.02 of the Revised Code to do all of the...

...(A) As used in sections 5160.45 to 5160.481 of the Revised Code, "information" means all of the following: (1) Records, as defined in section 149.011 of the Revised Code; (2) Any other documents in any format; (3) Data derived from records and documents that are generated, acquired, or maintained by the department of medicaid, a county department of job and family services, or an entity performing duties on ...

...(A) For the purposes of section 5160.45 of the Revised Code, an authorization shall be made on a form that uses language understandable to the average person and contains all of the following: (1) A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion; (2) The name or other specific identification of the person or class of persons authori...

... participate as an active member in the public assistance reporting information system; (2) Explore joining other multistate cooperatives, such as the national accuracy clearinghouse, to identify individuals enrolled in public assistance programs outside of this state. (B) The department may disclose information regarding a medical assistance recipient to the extent necessary to participate as an active member in t...

...edicaid shall review information in the public assistance reporting information system to determine whether an individual who is a medical assistance recipient may be eligible for federal military-related health care benefits. If the department determines that the individual may be eligible for federal military-related health care benefits, it shall notify the individual of the potential eligibility and encourage the...

...(A) The medicaid director shall adopt rules under section 5160.02 of the Revised Code implementing sections 5160.45 to 5160.481 of the Revised Code and governing the custody, use, disclosure, and preservation of the information generated or received by the department of medicaid, county departments of job and family services, other state and county entities, contractors, grantees, private entities, or officials...

...481 of the Revised Code to prevent the publication or disclosure of names, lists, or other information concerning those recipients.

...The department of medicaid shall administer the refugee medical assistance program authorized by the "Immigration and Nationality Act," section 412(e), 8 U.S.C. 1522(e).

...The medicaid director may provide for the department of medicaid to develop, participate in the development of, negotiate, and enter into one or more interstate compacts on behalf of this state with agencies of any other states, for the provision of medical assistance to children in relation to whom all of the following apply: (A) They have special needs. (B) This state or another state that is a party to the...

...Whoever violates division (B) of section 5160.45 of the Revised Code is guilty of a misdemeanor of the first degree.

...(A) As used in the Revised Code, "children's health insurance program" and, when used as an acronym for the children's health insurance program, "CHIP" mean the program of child health assistance authorized by Title XXI of the "Social Security Act," 42 U.S.C. 1397aa et seq. CHIP part I, CHIP part II, and CHIP part III, as authorized by this chapter, are components of CHIP. Any reference in statute enacted by th...

...The medicaid director may adopt rules in accordance with Chapter 119. of the Revised Code as necessary for the efficient administration of the children's health insurance program, including rules that establish all of the following: (A) The conditions under which the program will pay for health benefits coverage; (B) The method of the payment; (C) The amount of payment, or the method by which the amount is t...

...The medicaid director may continue to operate the component of the children's health insurance program initially authorized by an executive order issued under section 107.17 of the Revised Code as long as federal financial participation is available for the program. If operated, the component shall pay for part or all of the cost of health benefits coverage for uninsured individuals under nineteen years of age ...

...The component of the children's health insurance program authorized by section 5161.05 of the Revised Code shall be known as CHIP part I.

...In accordance with federal law governing the children's health insurance program, the medicaid director may submit a state child health plan to the United States secretary of health and human services to pay, except as provided in section 5161.22 of the Revised Code, for part or all of the cost of health benefits coverage for uninsured individuals under nineteen years of age with family incomes above one hundre...

...The component of the children's health insurance program authorized by section 5161.10 of the Revised Code shall be known as CHIP part II.

...If the medicaid director submits a state child health plan to the United States secretary of health and human services under section 5161.10 of the Revised Code and the secretary approves the plan, the director shall implement CHIP part II in accordance with the plan. ; .