Ohio Revised Code Search

...on of the contract as determined by the life expectancy of the insured; (b) The comparison omits from consideration any benefit or value provided in the contract, any differences as to amount or period of rates, or any differences in limitations or conditions or other provisions that directly or indirectly affect the benefits. In any determination of the incompleteness or misleading character of any comparison or s...

...testability. (D) The superintendent of insurance may require from any society or association, by examination or otherwise, such information as will enable the superintendent to determine whether the society or association is exempt from the requirements of this chapter. (E) Societies that, pursuant to division (A) of this section, are exempt from the requirements of this chapter shall also be exempt from all other ...

...s and findings of the superintendent of insurance made under the provisions of this chapter are subject to review by the proper proceedings in any court of competent jurisdiction in this state.

...(A) Whoever violates division (A) of section 3921.36 of the Revised Code or knowingly receives any compensation or commission by or in consequence of such violation, is guilty of a misdemeanor of the first degree, and shall in addition be liable for a civil penalty in the amount of three times the sum received by the violator as compensation or commission, which penalty may be sued for and recovered by any person or ...

...al's eligibility for individual health insurance coverage, including coverage offered to individuals through a nonemployer group, to participate in a plan or health insurance coverage; (c) A determination that a health care service is not a covered benefit; (d) The imposition of an exclusion, including exclusions for pre-existing conditions, source of injury, network, or any other limitation on benefits that ...

...(A) A covered person may make a request for an external review of an adverse benefit determination. (B) All requests for external review shall be made in writing, including by electronic means, by the covered person to the health plan issuer within one hundred eighty days of the date of the final adverse benefit determination. However, in the case of an expedited external review under section 3922.09 of the ...

...lity of any applicable office of health insurance assistance, ombudsman program, or other similar program in this state to assist consumers.

...plan issuers offering individual health insurance coverage, including coverage offered to individuals through nonemployer groups shall not require more than one level of internal appeal before the individual may request an external review.

...xternal review by the superintendent of insurance for an adverse benefit determination by the health plan issuer based on a contractual issue that did not involve a medical judgment or any medical information, pursuant to section 3922.11 of the Revised Code. (C) For an adverse benefit determination in which emergency medical services have been determined to be not medically necessary or appropriate after an ex...

...organization, and the superintendent of insurance. Upon receipt of such a notification, the assigned independent review organization shall terminate the associated external review.

...In addition to the information provided under division (D)(1)(b) of section 3922.05, division (B) of section 3922.08, division (C) of section 3922.09, and division (D) of section 3922.10 of the Revised Code, an assigned independent review organization, to the extent that such documents are available and appropriate, shall consider all of the following when conducting its review: (A) The covered person's medic...

...plan issuer, and the superintendent of insurance.

...edures adopted by the superintendent of insurance and eligible for expedited external review under division (A) of this section. The health plan issuer shall immediately notify the covered person of its determination in accordance with any associated rules, policies, or procedures adopted by the superintendent of insurance. (C) If a request for an expedited review is complete and eligible, the health plan issu...

...edures adopted by the superintendent of insurance and eligible for expedited external review under division (C)(1) of this section. The health plan issuer shall immediately notify the covered person of its determination in accordance with any associated rules adopted by the superintendent of insurance. (D) The health plan issuer shall provide to the assigned independent review organization all documents and inf...

...(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 ...

...e 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 the covered person has other remedies available under applicable federal or state law, or unless the superintendent determines that, due to the facts and circumstan...

...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...

... be accredited by the superintendent 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 st...

...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...

...dures adopted by the superintendent of insurance. A health plan issuer shall maintain written records on all requests for external review for at least three years. (C) The superintendent shall compile and annually publish the information collected under this section and report the information to the governor, the speaker and minority leader of the house of representatives, the president and minority leader of ...

...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 ...

...ination would seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, the covered person may file a request for an expedited external review to be conducted simultaneously with the expedited internal appeal, pursuant to section 3922.09 of the Revised Code. (2) If the adverse benefit determination involves a denial of coverage based on...

...Consistent with the Rules of Evidence, a written decision or opinion prepared by an independent review 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 kno...

...n 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 under section 149.43 of the Revised Code, except to the extent that information from the record is used in preparin...