Ohio Revised Code Search

...t of the employee's premium rate to any health insuring corporation holding a certificate of authority pursuant to this chapter. The employee's authorization shall be evidenced by approval of the head of the department, division, office, or institution in which the employee is employed. (B) In the case of employees of the state, the employee's authorization shall be directed to and filed with the director of admini...

...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.

...us months. (2) "Clinical peer" means a health care practitioner in the same, or in a similar, specialty that typically manages the medical condition, procedure, or treatment under review. (3) "Covered person" means a person receiving coverage for health services under a policy, contract, or agreement issued by a health insuring corporation. (4) "Emergency services" has the same meaning as in section 1753.28 of the...

...Each health insuring 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 progra...

... section 1751.73 of the Revised Code, a health insuring corporation shall do both of the following: (1) Develop and maintain the appropriate infrastructure and disclosure systems necessary to measure and report, on a regular 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...

...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...

...termination" means a determination by a health insuring corporation or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based upon the information provided, the health care service does not meet the requirements for benefit payment under the health insuring corporation's policy, contract, or agreement, and coverag...

... 3922. of the Revised Code apply to any health insuring corporation that 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 connecti...

...A health insuring corporation that conducts utilization review shall prepare a written utilization review program that describes all review activities, both delegated and 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 ...

...The utilization review program of a health insuring corporation shall be implemented in accordance with all of the following: (A) The program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health insuring corporation may develop its own clinical review criteria or may purchase or license such criteria from qualified...

...ond opinion that may be required (B) A health insuring corporation shall maintain written procedures 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 prospe...

...section 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...

...or a concurrent review determination, a health insuring corporation shall give the provider or health 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 enrolle...

...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.

...A health insuring corporation shall establish and maintain an internal review system that has been approved by the superintendent of insurance. The system shall provide for review by a clinical peer and include adequate and reasonable procedures for review and resolution of appeals from enrollees concerning adverse determinations made under section 1751.81 of the Revised Code, including procedures for verifying...

...Revised Code, each individual and group health insuring corporation policy, contract, or agreement providing basic health care services that is delivered, issued for delivery, or renewed in this state shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder. A health insuring corporation shall not terminate an individual's coverage, or refuse to deliver, execute, issue, amend, ad...

...on 3963.01 of the Revised Code. (B) A health insuring corporation shall provide the information required in this division to all enrollees receiving coverage under an individual or group health insuring corporation policy, contract, or agreement for vision care services, vision care materials, or dental care services. The information shall be in a conspicuous format, shall be easily accessible to enrollees, and sha...

...(A) No health insuring corporation shall fail to comply with sections 1751.77 to 1751.82 of the Revised Code. (B) Whoever violates division (A) of this section is deemed to have engaged in an unfair and deceptive act or practice in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code.

...tion 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.

...ised Code. (B) No individual or group health insuring corporation policy, contract, or agreement shall 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, restrictio...

...A health insuring corporation may provide payment or reimbursement to a 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 ...

...Each health insuring corporation shall comply with the requirements of section 3959.20 of the Revised Code as they pertain to health plan issuers. As used in this section, "health plan issuer" has the same meaning as in section 3922.01 of the Revised Code.