Ohio Revised Code Search

...her 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 rendered to beneficiaries, up to the limits and exclusio...

...ccordance with this section. (B)(1) Unless division (B)(2) or (3) of this section applies, when a third-party payer receives from a provider or beneficiary a claim on the standard claim form prescribed in rules adopted by the superintendent of insurance under section 3902.22 of the Revised Code, the third-party payer shall pay or deny the claim not later than thirty days after receipt of the claim. When a third-par...

...ired 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 pursuant to that act, sections 3901.381, 3901.384, 3901.385, 3901.389, 3901.3810, 3901.3811, 3901.3812, and 3901.3813 of the Revised Code apply to a claim submitted to a third-party payer for payment for health care serv...

...901.381 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 receipt of a claim form. The contractual arrangement may include periodic interim payment arrangements, capitation payment arrangemen...

...rvice for which reimbursement is sought under the claim, the third-party payer shall pay or deny the claim not later than ninety days after receipt of the claim or, alternatively, pursuant to the requirements of sections 3901.381 to 3901.388 of the Revised Code. The third-party payer must make an election to process such claims either within the ninety-day period or under section 3901.381 of the Revised Code. If the ...

...pital or the treatment has not been completed, if the submitted claim covers services actually rendered and charges actually incurred over at least a thirty-day period.

...arty payer shall accept and honor a completed and validly executed assignment of benefits with a hospital by a beneficiary, except when the third-party payer has notified the hospital in writing of the conditions under which the third-party payer will not accept and honor an assignment of benefits. Such notice shall be made annually. (C) A third-party payer may not refuse to accept and honor a validly executed assig...

...e system. (2) If a third-party payer delegates the processing of payments to another entity, the third-party payer shall require the entity to comply with division (B)(1) of this section on behalf of the third-party payer.

... thirty days after the notice is made, elects not to appeal the determination, or appeals the determination but the appeal is not upheld, the third-party payer may initiate recovery of the overpayment. When a provider has failed to make a timely response to the notice of the third-party payer's determination of overpayment, the third-party payer may recover the overpayment by deducting the amount of the overpayment ...

... a record of the day the payment was mailed, there exists a rebuttable presumption that the payment was made five business days before the day the payment was received by the provider, unless it can be proven otherwise. (2) If the third-party payer or a person acting on behalf of the third-party payer submits a payment directly to a provider electronically, there exists a rebuttable presumption that the payment was...

...er or beneficiary who files a complaint under division (A) of this section. If a provider or beneficiary is aggrieved with respect to any act of the third-party payer that the provider or beneficiary believes to be retaliation for filing a complaint under division (A) of this section, the provider or beneficiary may file a written complaint with the superintendent regarding the alleged retaliation.

... the superintendent may examine data collected from the same time period as covered by these reports and the superintendent's examination findings may be used as the basis for finding a violation of division (A) of this section.

...wenty-five per cent of the total to the credit of the department of insurance operating fund created by section 3901.021 of the Revised Code; (2) Sixty-five per cent of the total to the credit of the general revenue fund; (3) Ten per cent of the total to the credit of claims processing education account, which is hereby created within the department of insurance operating fund created by section 3901.021 of 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.

...are advantage program operated under Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C. 301, as amended; (D) A third-party payer for coverage provided under the medicaid program; (E) A third-party payer for coverage provided under the tricare program offered by the United States department of defense.

... either on the health plan issuer's web site or through a means other than the contract offered to the health care provider. (E)(1) If a health care provider requests a change in the available payment method, the health plan issuer shall implement the change to the payment method selected by the health care provider within thirty-one business days. (2) The payment method selected by the health care provider shall...

..., or person for any services rendered unless the hospital is licensed under Chapter 3722. of the Revised Code. "Hospital" as used in this section means only those institutions included 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.

...ired pursuant to sections 3937.25, 3937.26, and 3937.27 of the Revised Code, or information otherwise required by a law other than this section relating to insurance. This section does not apply to disclosures through electronic media of certificates, explanation of benefit statements, and other mandated materials under the "Employee Retirement Income Security Act of 1974," 88 Stat. 829, 29 U.S.C. 1001, as amended, a...

...ical payment insurance; (d) Insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance; (e) A medicare supplement policy of insurance, as defined by the superintendent of insurance by rule; (f) Coverage under a plan through medicare, medicaid, or the federal employees benefit program;...

... acting as agents of the superintendent under the authority of this section and are not subject to civil liability for libel, slander, or any other cause of action by virtue of their collection, review, and analysis or dissemination of the data and information collected from the filings required under this section. (E)(1) In addition to the annual statement required to be filed with the national association of insur...

...l law enforcement investigatory records under section 149.43 of the Revised Code. Notwithstanding such section, 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 document...

...practice under sections 3901.19 to 3901.26 of the Revised Code.

...practice under sections 3901.19 to 3901.26 of the Revised Code.

...cident 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 insurance company, domiciled in the state of Indiana; (d) United fire insurance company, domiciled in t...

...dited 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 superintendent shall be the property of the superintendent. The original work papers or any copies of them, whether in possession of the certified public accountant or the department of insurance, are confidential and privileged and are not ...