Ohio Revised Code Search

...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 the benefits contract. (C) "Hospital" has the same meaning as 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-party payer denies a claim, the third-party payer shall notify the provider and the beneficiary. The notice shall state, with specificity, why the third-party payer denied the claim. (2)(a) Unless division (...

...specified in section 262 of the "Health Insurance Portability and Accountability Act of 1996," 110 Stat. 2027, 42 U.S.C.A. 1320d-4, on which a third-party payer is initially required 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, 3...

...(A) A provider and a third-party payer may do either 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 thir...

...(A) Subject to division (B) of this section, a third-party payer that requires timely submission of claims for payment for health care services shall process a claim that is not submitted in a timely manner if a claim for the same services was initially submitted to a different third-party payer or state or federal program that offers health care benefits and that payer or program has determined that it is not respon...

...A third-party payer shall not do either of the following: (A) Engage in any business 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 benefic...

...(A) Notwithstanding section 1751.13 or division (I)(2) of section 3923.04 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-p...

... to be duplicative by the 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 where...

...(A) A payment made by a third-party payer to a provider in accordance with sections 3901.381 to 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 a...

...(A) Any third-party payer that fails to comply with section 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 contrac...

...en 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 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 sectio...

...evised Code. (B) The superintendent of insurance may require third-party payers to submit reports of their compliance with division (A) of this section. If reports are required, 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 sup...

...(A) Every provider agreement with an ICF/IID provider shall do both of the following: (1) Except as provided by division (B) of this section, include any part of the ICF/IID that meets federal and state standards for medicaid certification; (2) Prohibit the provider from doing either of the following: (a) Discriminating against a resident on the basis of race, color, sex, creed, or national origin; (b) Subje...

...An ICF/IID resident has a cause of action against the provider of the ICF/IID for breach of the provider agreement obligations or other duties imposed by section 5124.08 of the Revised Code. The action may be commenced by the resident, or on the resident's behalf by the resident's sponsor, by the filing of a civil action in the court of common pleas of the county in which the ICF/IID is located or in the court ...

...k issued by the national association of insurance commissioners in effect at the time the claims were processed. Before imposing an administrative remedy, the superintendent shall provide written notice to the third-party payer informing the third-party payer of the reasons for the superintendent's finding, the administrative remedy the superintendent proposes to impose, and the opportunity to submit a written requ...

...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.

...(A) Except as provided in division (D) of this section and divisions (C)(2) and (4) of section 5124.101 of the Revised Code, each ICF/IID provider shall file with the department of developmental disabilities an annual cost report for each of the provider's ICFs/IID for which the provider has a valid provider agreement. The cost report for a year shall cover the calendar year or portion of the calendar year during whi...

... 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 of those sections to the plan and its administrators; (C) A third-party payer for coverage provided under the medicare advantage program operated under Title XV...

...(A) As used in this section: (1) "Health plan issuer" has the same meaning as in section 3922.01 of the Revised Code, except 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, digita...

...No insurance company, health insuring corporation, or self-insurance plan authorized to do business in this state shall include or provide in its policies or subscriber agreements for benefit payments or reimbursement for services in any hospital which is not licensed under Chapter 3722. of the Revised Code. No hospital located in this state shall charge any insurance company, health insuring corporation, federal, st...

...t 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; (d) A facsimile number. (3) "Insured" means a certificate holder...

...(A) The provider of an ICF/IID in peer group 1, peer group 2, peer group 3, or peer group 4 that becomes a downsized ICF/IID or partially converted ICF/IID on or after July 1, 2013, or becomes a new ICF/IID on or after that date, may file with the department of developmental disabilities a cost report covering the period specified in division (B) of this section if the following applies to the ICF/IID: (1) In the c...

...No ICF/IID provider shall report fines paid under section 5124.99 of the Revised Code in a cost report filed under section 5124.10, 5124.101, or 5124.522 of the Revised Code.

... 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 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 superinte...

...Cost reports shall be completed using the form prescribed under section 5124.104 of the Revised Code and in accordance with the guidelines established under that section.

...The department of developmental disabilities shall do all of the following: (A) Prescribe the form to be used for completing a cost report and a uniform chart of accounts for the purpose of reporting costs on the form; (B) Distribute a paper copy of the form, or computer software for electronic submission of the form, to each provider at least sixty days before the date the cost report is due; (C) Establish ...

...The department of developmental disabilities shall develop an addendum to the cost report form that an ICF/IID provider may use to set forth costs that the provider believes the department may dispute. The department may consider such costs in determining an ICF/IID's medicaid payment rate. If the department does not consider such costs in determining an ICF/IID's medicaid payment rate, the provider may seek re...

...nd alien insurer authorized to transact insurance in this state shall, annually on or before the first day of March of each year, file with the national association of insurance commissioners a copy of its annual statement convention blank, along with such additional filings as prescribed by the superintendent of insurance for the preceding year. The information filed with the association shall be in the same format ...

...(A) If an ICF/IID provider required by section 5124.10 of the Revised Code to file a cost report for the ICF/IID fails to file the cost report by the date it is due or the date, if any, to which the due date is extended pursuant to division (E) of that section, or files an incomplete or inadequate report for the ICF/IID under that section, the department of developmental disabilities shall do both of the follow...

...(A) Except as provided in division (B) of this section and not later than three years after an ICF/IID provider files a cost report with the department of developmental disabilities under section 5124.10 or 5124.101 of the Revised Code, the provider may amend the cost report if the provider discovers a material error in the cost report or additional information to be included in the cost report. The department ...

...The department of developmental disabilities shall conduct a desk review of all cost reports it receives under sections 5124.10, 5124.101, and 5124.522 of the Revised Code. Based on the desk review, the department shall make a preliminary determination of whether the reported costs are allowable costs. The department shall notify each ICF/IID provider of whether any of the reported costs are preliminarily deter...

...(A) The department of developmental disabilities may conduct an audit, as defined in rules adopted under section 5124.03 of the Revised Code, of any cost report filed under section 5124.10, 5124.101, or 5124.522 of the Revised Code. The decision whether to conduct an audit and the scope of the audit, which may be a desk or field audit, may be determined based on prior performance of the provider, a risk analysi...

...(A) As used in this section, "insurance fraud investigation" means any investigation conducted by the superintendent of insurance or a designee of the superintendent that relates to a fraudulent insurance act as defined in section 3999.31 of the Revised Code. (B) All documents, reports, and evidence in the possession of the superintendent or the superintendent's designee that pertain to an insurance fraud investiga...

...(A) Except as otherwise provided by section 5124.101 of the Revised Code, sections 5124.151 to 5124.154 of the Revised Code, and division (B) of this section, the total per medicaid day payment rate that the department of developmental disabilities shall pay to an ICF/IID provider for ICF/IID services the provider's ICF/IID provides during a fiscal year shall equal the sum of all of the following: (1) The per medi...

...(A) The total per medicaid day payment rate determined under section 5124.15 of the Revised Code shall not be the initial rate for ICF/IID services provided by a new ICF/IID. Instead, the initial total per medicaid day payment rate for ICF/IID services provided by a new ICF/IID shall be determined in accordance with this section. (B) The initial total per medicaid day payment rate for ICF/IID services provided by ...

...siness of life or sickness and accident insurance under Title XXXIX of the Revised Code or any person or governmental entity providing health services coverage for individuals on a self-insurance basis. (3) "Group policy" means, with respect to life insurance, a policy covering more than twenty-five individuals and issued pursuant to section 3917.01 of the Revised Code, and with respect to sickness and accident ins...

...(A) The total per medicaid day payment rate determined under section 5124.15 of the Revised Code shall not be paid for ICF/IID services provided by an ICF/IID, or discrete unit of an ICF/IID, designated by the department of developmental disabilities as an outlier ICF/IID or unit. Instead, the provider of a designated outlier ICF/IID or unit shall be paid each fiscal year a total per medicaid day payment rate that th...

...In underwriting an individual policy of life or sickness and accident insurance or a group policy of life or sickness and accident insurance providing coverage for members of a membership organization, an insurer may require an applicant for coverage under the policy to submit to an HIV test only in conjunction with tests for other health conditions. No applicant shall be required to submit to an HIV test on the basi...

...(A) To the extent, if any, provided for in rules authorized by this section, the total per medicaid day payment rate determined under section 5124.15 of the Revised Code shall not be paid for ICF/IID services that an ICF/IID not designated as an outlier ICF/IID or unit provides to a resident who meets the criteria for admission to a designated outlier ICF/IID or unit, as specified in rules authorized by section...

...The department of developmental disabilities is not required to pay the total per medicaid day payment rates determined under section 5124.15 of the Revised Code for ICF/IID services provided by developmental centers. Instead, the department may determine the medicaid payment rates for developmental centers according to the reasonable cost principles of Title XVIII.

... to write life or sickness and accident 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 ...

...ic accountant performing an audit of an insurance company or health insuring corporation doing business in this state that is required by rule or by any section of the Revised Code to file an audited 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 sup...

...(A) For each fiscal year, the department of developmental disabilities shall determine each ICF/IID's per medicaid day capital component rate. An ICF/IID's rate for a fiscal year shall equal the sum of the following: (1) The lesser of the following: (a) The sum of all of the following: (i) The ICF/IID's per diem fair rental value rate for the fiscal year as determined under division (B) of this section; (ii) ...

...(A) For each fiscal year, the department of developmental disabilities shall determine each ICF/IID's per medicaid day direct care costs component rate. An ICF/IID's rate shall be determined as follows: (1) Determine the product of the following: (a) The ICF/IID's quarterly case-mix score determined or assigned under section 5124.193 of the Revised Code for the following calendar quarter: (i) For the rate deter...

...(A) As used in sections 5124.191 to 5124.193 of the Revised Code, "ICF/IID resident" includes an individual who is on hospital or therapeutic leave from an ICF/IID. (B) In accordance with rules adopted under section 5124.03 of the Revised Code, the department of developmental disabilities shall assess each ICF/IID resident regardless of payment source and compile complete assessment data on the residents. The depar...

...(A) The department of developmental disabilities shall establish six acuity groups for the purpose of assigning case-mix scores to ICF/IID residents. An ICF/IID resident's case-mix score shall be the score of the resident's acuity group as specified in rules authorized by this section. (B) The department shall place each ICF/IID resident into one of the acuity groups. In determining which acuity group an ICF/IID re...

...(A) Except as provided in division (B) of this section, the department of developmental disabilities shall do both of the following: (1) For each calendar quarter, determine a case-mix score for each ICF/IID using both of the following: (a) The most recent (as of the date the determination is made) resident assessment data compiled and revised for the ICF/IID's residents under section 5124.191 of the Revised Code...

...(A) No change that the department of developmental disabilities makes to either of the following is valid unless the change is applied prospectively and the department complies with division (B) of this section: (1) The department's instructions or guidelines for the resident assessment instrument used to compile or revise assessment data of ICF/IID residents under section 5124.191 of the Revised Code; (2) The me...

...(A) For each fiscal year, the department of developmental disabilities shall determine each ICF/IID's per medicaid day indirect care costs component rate. An ICF/IID's rate shall be the lesser of the individual rate determined under division (B) of this section and the maximum rate determined for the ICF/IID's peer group under division (C) of this section. (B) An ICF/IID's individual rate is the sum of the followin...

...For each fiscal year, the department of developmental disabilities shall determine each ICF/IID's per medicaid day other protected costs component rate. An ICF/IID's rate shall be the ICF/IID's desk-reviewed, actual, allowable, per diem other protected costs from the applicable cost report year, adjusted for inflation using the following: (A) Subject to division (B) of this section, the consumer price index for all...