Ohio Revised Code Search

...edited and do not involve an experimental or investigational treatment. (B) Within five days after the receipt of a request for an external review that is complete and valid, the health plan issuer shall provide to the assigned independent review organization all documents and information considered in making the adverse benefit determination. (C) An external review shall not be delayed due to failure on th...

... make a request for an expedited external review, except as provided in division (I) of this section: (1) After an adverse benefit determination, if both of the following apply: (a) The covered person's treating physician certifies that the adverse benefit determination involves a medical condition that could seriously jeopardize the life or health of the covered person, or would jeopardize the covered perso...

...ns of this section apply only to external reviews that involve an experimental or investigational treatment. (A) A covered person may request an external review of an adverse benefit determination based on the conclusion that a requested health care service is experimental or investigational, except when the requested health care service is explicitly listed as an excluded benefit under the covered person's b...

...(A) The superintendent of insurance shall establish and maintain a system for receiving and reviewing requests for external review for adverse benefit determinations where the determination by the health plan issuer was based on a contractual issue and did not involve a medical judgment or a determination based on any medical information, except for emergency services, as specified in division (C) of section 3922.05 ...

...(A) An external review decision is binding on the health plan issuer except to the extent the health plan issuer has other remedies available under applicable state law, or unless the superintendent of insurance determines that, due to the facts and circumstances of an external review, a second external review is required. (B) An external review decision is binding on the covered person except to the extent t...

...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...

...intendent 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 standard external review proc...

...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...

...of the Revised Code to conduct an external review shall maintain written records in accordance with the associated rules established by the superintendent, in the aggregate by state, and by the health plan issuer, on all external reviews requested and conducted during a calendar year. Each independent review organization shall submit this information to the superintendent, upon request, in a report in the fo...

...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 ...

...(A) Each health plan issuer shall include a description of its external review procedures, including the superintendent's contractual review, in, or attached to, the policy, certificate, membership booklet, or outline of coverage, or other evidence of coverage it provides to covered persons. This disclosure shall be in a form prescribed by the superintendent in any associated rules, policies, or procedures. ...

...view 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 knowledge at the time it was written. Consistent with the Rules of Evidence, any party to a civil ...

...ing information pertaining to the medical history, diagnosis, prognosis, or medical condition of a covered person 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 un...

...out the purposes of this chapter and shall prescribe forms relating to notices, appeals, and requests for external review under this chapter.

...practice under sections 3901.19 to 3901.26 of the Revised Code. Additionally, health plan issuers holding a certificate of authority from the superintendent are also subject to the following: (A) If, after notice 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 issu...

... Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended, shall be considered one employer. In the case of an employer that was not in existence throughout the preceding calendar year, the determination of whether the employer is a small or large employer shall be based on the average number of eligible employees that it is reasonably expected the employer will employ on business days in the current calendar...

... Revenue Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. (B) Notwithstanding division (A) of this section, divisions (D), (E)(2), (F), and (G) of section 3924.03 of the Revised Code and section 3924.04 of the Revised Code do not apply to health benefit policies that are not sold to owners of small businesses as an employment benefit plan. Such policies shall clearly state that they are not being sold as a...

...wise provided in section 2721 of the "Health Insurance Portability and Accountability Act of 1996," Pub. L. No. 104-191, 110 Stat. 1955, 42 U.S.C.A. 300gg-21, as amended, health benefit plans covering small employers are subject to the following conditions, as applicable: (A)(1) Pre-existing conditions provisions shall not exclude or limit coverage for a period beyond twelve months, or eighteen months in the case of...

...n 3924.032 of the Revised Code: (1) "Health status-related factor" means any of the following: (a) Health status; (b) Medical condition, including both physical and mental illnesses; (c) Claims experience; (d) Receipt of health care; (e) Medical history; (f) Genetic information; (g) Evidence of insurability, including conditions arising out of acts of domestic violence; (h) Disability. (2) "Network plan" me...

...(A) A carrier may refuse to issue health benefit plans in the small employer market if the carrier has demonstrated both of the following to the superintendent of insurance: (1) The carrier does not have the financial reserves necessary to underwrite additional coverage. (2) The carrier is applying division (A) of this section uniformly to all employers in the small employer market in this state consistent with the...

... in connection with the offering of a health benefit plan to a small employer, shall disclose to the employer, as part of its solicitation and sales materials, the following information: (1) The provisions of the plan concerning the carrier's right to change premium rates and the factors that may affect changes in premium rates; (2) The provisions of the plan relating to renewability of coverage; (3) The provision...

...(A)(1) With respect to any health benefit plan of a carrier and except as otherwise provided in divisions (A)(2) and (3) of this section, the premium rates charged or offered for a rating period for the same or similar coverage under a health benefit plan covering any small employer with similar case characteristics shall not vary from the applicable midpoint rate by more than forty per cent of the midpoint rate, as...

...924.01 to 3924.06 of the Revised Code shall be demonstrated through actuarial certification. Carriers offering health benefit plans to small employers shall file annually with the superintendent of insurance an actuarial certification stating that the underwriting and rating methods of the carrier do all of the following: (1) Comply with accepted actuarial practices; (2) Are uniformly applied to health benefit p...

...his section: (1) "Beneficiary," "hospital," and "third-party payer" have the same meanings as in section 3901.38 of the Revised Code. (2) "Overcharged" means charged more than the usual and customary charge, rate, or fee that is charged by the provider or hospital for a particular item or service. (3) "Provider" has the same meaning as in section 3902.11 of the Revised Code. (B) If a beneficiary identifies on th...