Ohio Revised Code Search

... framework to assist the insurer with identifying, assessing, monitoring, managing, and reporting on its material and relevant risks. This requirement may be satisfied if the insurance group of which the insurer is a member maintains a risk management framework applicable to the operations of the insurer.

...e insurer is a member, shall regularly conduct an own risk and solvency assessment consistent with a process comparable to the own risk and solvency assessment guidance manual. The own risk and solvency assessment shall be conducted not less than annually, but also at any time when there are significant changes to the risk profile of the insurer or the insurance group of which the insurer is a member.

...y combination of reports that together contain the information described in the own risk and solvency assessment guidance manual, applicable to the insurer or the insurance group of which it is a member. (2) Notwithstanding any request from the superintendent, if the insurer is a member of an insurance group, the insurer shall submit the report required by division (A)(1) of this section if the superintendent...

...uest for waiver, the superintendent may consider any of the following: (a) The type and volume of business written; (b) The ownership and organizational structure of the insurer or insurance group of which the insurer is a member; (c) Any other factor the superintendent considers relevant to the insurer or insurance group of which the insurer is a member. (2) If the insurer is part of an insurance group with ...

...g information shall be maintained and made available for examination upon request of the superintendent of insurance. (B) The superintendent's review of the own risk and solvency assessment summary report, and any additional requests for information, shall be made using similar procedures used in the analysis and examination of multi-state or global insurers and insurance groups.

...rt, in the possession or control of the department of insurance that are obtained by, created by, or disclosed to the superintendent of insurance, or any other person under sections 3901.371 to 3901.378 of the Revised Code, are recognized by this state as being proprietary and to contain trade secrets. (B) The documents described in division (A) of this section shall be confidential by law and privileged, and ...

... 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 rendered to beneficiaries, up to the limits and exclusions contained in t...

...d beneficiary coverage under a benefits contract, confirmation of premium payment, medical information regarding the beneficiary and the services provided, information on the responsibility of another third-party payer to make payment or confirmation of the amount of payment by another third-party payer, and information that is needed to correct material deficiencies in the claim related to a diagnosis or treatment o...

... and third-party payer may enter into a contractual arrangement under which the third-party payer agrees to process claims that are not submitted electronically because of the financial hardship that electronic submission of claims would create for the provider or any other extenuating circumstance.

...her 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 third-party payer is not directly related to the rece...

...hall not affect the terms of a benefits contract. (C) For purposes of this section, both of the following apply: (1) A determination that a third-party payer or state or federal program is not responsible for the cost of health care services includes a determination regarding coordination of benefits, preexisting health conditions, ineligibility for coverage at the time services were provided, subrogation provision...

...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 beneficiary has not been discharged from the hospital or the treatment has not been completed...

...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-party payer and the hospital have not entered into a contract regarding ...

...he department of insurance shall not be considered by the department in a market conduct examination of a third-party payer's compliance with section 3901.381 of the Revised Code. The superintendent of insurance shall have the discretion to exclude an original claim in determining a violation under section 3901.381 of the Revised Code. (B)(1) A third-party payer shall establish a system whereby a provider and a ben...

...o 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 an overpayment if the recovery process is initiated not later than two years after the payment ...

...on 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 contractual payment arrangement entered into under section 3901....

...(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 ...

... the superintendent shall prescribe the content, format, and frequency of the reports in consultation with third-party payers. The superintendent shall not require reports to be submitted more frequently than once every three months. The superintendent shall not use findings from reports submitted by a third-party payer under this division as the basis of a finding of a violation of division (A) of this section or t...

...ies 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 specified in division (B) of this section. In making a finding under this division, the superintendent shall apply the error tolerance standards for claims processing contained ...

...e 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.

... 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 application of any provisions ...

... 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, digital, facsimile, physical, or paper format. (4) "Business day" has the same meaning as in section 3901.81 of the Revised Code. ...

...uded within the definition of that term contained in section 3727.01 of the Revised Code, and the prohibitions in this section do not apply to facilities excluded from that definition.

...ransactions between two or more persons conducting business pursuant to the laws of this state relating to insurance. (2) "Contact point" means any electronic identification to which messages can be sent, including, but not limited to, any of the following: (a) An electronic mail address; (b) An instant message identity; (c) A wireless telephone number, or any other personal electronic communication device; ...

...ffered, or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a vision or dental benefit plan. "Health benefit plan" does not include any of the following: (a) A plan of self-insurance; (b) Insurance arising out of workers' compensation; (c) Automobile medical payment insurance; (d) Insurance under which benefits are payable with or...