Ohio Revised Code Search

...The superintendent shall accredit independent review organizations as prescribed by this section. (A) The superintendent shall develop an application form to accredit and renew accreditation of an independent review organization. (B) An independent review organization seeking to be accredited by the superintendent, or to renew its accreditation, shall submit the application form and include with the form all...

... be accredited by the superintendent of insurance to conduct external reviews under section 3922.13 of the Revised Code, in addition to the requirements provided in section 3922.13 of the Revised Code and any associated rules adopted by the superintendent, an independent review organization shall do all of the following: (1) Develop and maintain written policies and procedures that govern all aspects of both the st...

...All clinical reviewers assigned by an independent review organization to conduct external reviews shall have the same license as the health care provider of the service in question, and shall be physicians or other appropriate health care providers who meet all of the following minimum qualifications: (A) Be an expert in the treatment of the medical condition that is the subject of the external review; (B) B...

...(A) Nothing in this chapter shall be construed to create a cause of action against any of the following: (1) An employer that provides health care benefits to employees through a health plan issuer; (2) A clinical reviewer or independent review organization that participates in an external review under this chapter; (3) A health plan issuer that provides coverage for benefits pursuant to this chapter. (B) A...

...dures adopted by the superintendent of insurance. A health plan issuer shall maintain written records on all requests for external review for at least three years. (C) The superintendent shall compile and annually publish the information collected under this section and report the information to the governor, the speaker and minority leader of the house of representatives, the president and minority leader of ...

...The health plan issuer against which a request for a standard external review or an expedited external review is filed shall pay the cost of the external review, including the cost of any external review that is required at the direction of the superintendent. If the superintendent determines that, due to the facts and circumstances of an external review, a second external review is required, the health plan issuer ...

...rm prescribed by the superintendent of insurance. (D) For an adverse benefit determination that is not a final adverse benefit determination, the health plan issuer shall include with the notice required under division (C) of this section a statement informing the covered person of all of the following: (1) If the covered person's treating physician certifies in writing that the covered person has a medical c...

...Consistent with the Rules of Evidence, a written decision or opinion prepared by an independent review organization under this chapter shall be admissible in any civil action related to the coverage decision that was the subject of the decision or opinion. The independent review organization's decision or opinion shall be presumed to be a scientifically valid and accurate description of the state of medical kno...

...n is provided to the superintendent of insurance for any reason under this chapter or sections 1751.77 to 1751.87 of the Revised Code, regardless of the source, the superintendent shall maintain the confidentiality of the record. The record in the superintendent's possession is not a public record under section 149.43 of the Revised Code, except to the extent that information from the record is used in preparin...

...The superintendent may adopt rules under Chapter 119. of the Revised Code to carry out the purposes of this chapter and shall prescribe forms relating to notices, appeals, and requests for external review under this chapter.

...ice and hearing, the superintendent of insurance finds that a health plan issuer has failed to comply with the requirements of this chapter, the superintendent may suspend or revoke the health plan issuer's license to transact business within the state. (B)(1) In lieu of the suspension or revocation of a license under division (A) of this section, the superintendent of insurance, pursuant to an adjudication he...

...pter, "policy of sickness and accident insurance" includes any policy, contract, or certificate of insurance against loss or expense resulting from the sickness of the insured, or from the bodily injury or death of the insured by accident, or both, that is delivered, issued for delivery, renewed, or used in this state on or after the date occurring six months after the effective date of this amendment.

... in any policy of sickness and accident insurance delivered, issued for delivery, or used in this state, unless otherwise provided in the policy or in an indorsement thereon or in a rider attached thereto: (A) "Total disability" means inability to perform the duties of any gainful occupation for which the insured is reasonably fitted by training, experience, and accomplishment. (B) "Confinement to house" includes t...

...ion of, any group sickness and accident insurance policy delivered, issued for delivery, or used in this state, and no policy of sickness and accident insurance shall be delivered, issued for delivery, or used in this state, nor shall any indorsement, rider, or application which becomes or which is designed to become a part of any such policy or certificate be delivered, issued for delivery, or used in this state, un...

...ividual policy of sickness and accident insurance" includes sickness and accident insurance made available by insurers in the individual market to individuals, with or without family members or dependents, through group policies issued to one or more associations or entities. (B) With respect to any filing, made pursuant to section 3923.02 of the Revised Code, of any premium rates for any individual policy of sickn...

...coverage minus the sum of the amount of claims for losses paid; the amount of losses incurred but not reported; the amount incurred for state fees, federal and state taxes, and reinsurance; and the incurred costs and expenses related, either directly or indirectly, to the payment of commissions, measures to control fraud, and managed care. (b) "Administrative expense" does not include any amounts collected, or admin...

...No policy of sickness and accident insurance shall be delivered, issued for delivery, or used in this state unless all the following requirements are complied with: (A) The entire money and other considerations therefor are expressed therein. (B) The time at which insurance takes effect and terminates is expressed therein. (C) It purports to insure only one person, except that a policy may be issued to the head of...

...rovision as follows: Time of payment of claims. Indemnities payable under this policy for any loss, other than loss for which this policy provides any periodic payment, will be paid immediately upon, or within thirty days after, receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid ________ and any...

...under a policy of sickness and accident insurance or a public employee benefit plan. (4) "Emergency service" has the same meaning as in section 1753.28 of the Revised Code. (5) "Fraudulent or materially incorrect information" means any type of intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to the covered person in question....

...ode, no policy of sickness and accident insurance delivered, issued for delivery, or used in this state shall contain provisions respecting the matters set forth in this section unless such provisions are in the words in which the same appear in this section. Any such provisions in any such policy shall be preceded by the appropriate caption appearing in this section or, at the option of the insurer, by such appropri...

...in each policy of sickness and accident insurance in the order in which such policy provisions are set forth in sections 3923.04 and 3923.05 of the Revised Code or, at the option of the insurer, any such policy provision may be printed as a unit in any part of any such policy along with other policy provisions to which such policy provision may be logically related, provided the resulting policy shall not be wholly o...

...(A) On and after January 1, 2003, any insurance company authorized to do business in this state shall pay interest, in accordance with division (B) of this section and subject to division (C) of this section, on any proceeds that become due pursuant to the terms of a policy of sickness and accident insurance due to the death of the insured by sickness or accident. (B) The interest payable pursuant to division (A) of...

...ed by a policy of sickness and accident insurance, the insurer shall, with the approval of the superintendent of insurance, omit from such policy any inapplicable provision or part of a provision and shall, with the approval of the superintendent, modify any inconsistent provision or part of a provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the po...

...Any policy of sickness and accident insurance, indorsement, rider, or application which could have been lawfully delivered, issued for delivery, or used in this state on October 1, 1953, may be delivered, issued for delivery, or used in this state until January 1, 1956, without being subject to sections 3923.04 to 3923.07, inclusive, of the Revised Code. A copy of the form of any policy of sickness and accident insu...

...h the approval of the superintendent of insurance, insert in any policy of sickness and accident insurance, delivered, issued for delivery, or used in this state, any provision required by the laws of the state or the country in which such insurer is domiciled, if such provision is not substantially in conflict with any law of this state. Any domestic insurer may insert in any such policy issued for delivery in anot...