Ohio Revised Code Search

...ures 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 issuer...

...ures 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 infor...

...nt, in accordance with any associated rules, policies, or procedures adopted by the superintendent of insurance. (C) On receipt of a request from a health plan issuer, the superintendent shall consider whether the health care service is a service covered under the terms of the covered person's policy, contract, certificate, or agreement, except that the superintendent shall not conduct a review under this section u...

...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 circumstance...

...ndependent review organization is eligible for accreditation by the superintendent under this section only if it is accredited by a nationally recognized private accrediting entity that the superintendent has determined has accreditation standards that are equivalent to or exceed the minimum qualifications for independent review organizations under section 3922.14 of the Revised Code. (2) The superintendent may...

...f 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 process and the expedited external review process set forth in this chapter, including a quality assurance mechanism that does all of the following: (a) Ensu...

...ect of the external review; (B) Be knowledgeable about the requested health care service through clinical experience, within the last three years, treating patients with the same, or a similar, medical condition, and, in the case of an external review of an experimental or investigational health care service, be an expert, through clinical experience in the last three years, in the treatment of the covered per...

...al review under this chapter is not liable in damages in a civil action for injury, death, or loss to person or property and is not subject to professional disciplinary action for making, in good faith, any finding, conclusion, or determination required to complete the external review. (C) This section does not grant immunity from civil liability or professional disciplinary action to an independent review org...

...res 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 th...

...ew 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 shall pay the costs of the second review.

...al review processes, including the web site, telephone number, and mailing address of the superintendent's office of consumer services. (3) In the case of a notice of a final adverse benefit determination subsequent to an internal appeal, in addition to the information required under division (C)(2) of this section, the notice must also include a discussion of the decision. (4) Any written notice provided unde...

...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...

...7 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 preparing reports under section 3922.17 of the Revised Code. (B) Notwithstanding division (A) of this secti...

...The superintendent may adopt rules under Chapter 119. of the Revised Code to carry out the purposes of this chapter and shall prescribe forms relating to notices, appeals, and requests for external review under this chapter.

...be paid into the state treasury to the credit of the department of insurance operating fund. (2) If the superintendent for any reason has cause to believe that any violation of the requirements of this chapter has occurred or is threatened, the superintendent may give notice to the health plan issuer and to the representatives or other persons who appear to be involved in the suspected violation to arrange a ...

...er, "policy of sickness and accident insurance" includes any policy, contract, or certificate of insurance against loss or expense resulting from the sickness of the insured, or from the bodily injury or death of the insured by accident, or both, that is delivered, issued for delivery, renewed, or used in this state on or after the date occurring six months after the effective date of this amendment.

... for delivery, or used in this state, unless otherwise provided in the policy or in an indorsement thereon or in a rider attached thereto: (A) "Total disability" means inability to perform the duties of any gainful occupation for which the insured is reasonably fitted by training, experience, and accomplishment. (B) "Confinement to house" includes the activities of a convalescent not able to be gainfully employed. ...

...s been filed with the superintendent, unless he has previously given to the insurer his written approval thereto. If the superintendent finds that any such form of policy, certificate, indorsement, rider, or application which has been filed with him by an insurer contains any provision which is contrary to the law of this state, or contains inconsistent provisions, or contains any question, provision, title, heading,...

...idual policy of sickness and accident insurance" includes sickness and accident insurance made available by insurers in the individual market to individuals, with or without family members or dependents, through group policies issued to one or more associations or entities. (B) With respect to any filing, made pursuant to section 3923.02 of the Revised Code, of any premium rates for any individual policy of sicknes...

...ntendent into the state treasury to the credit of the department of insurance operating fund. (G) The statement of aggregate expenses filed pursuant to this section separately detailing an insurer's individual, small group, and large group business shall be considered work papers resulting from the conduct of a market analysis of an entity subject to examination by the superintendent under division (C) of section 39...

...d for delivery, or used in this state unless all the following requirements are complied with: (A) The entire money and other considerations therefor are expressed therein. (B) The time at which insurance takes effect and terminates is expressed therein. (C) It purports to insure only one person, except that a policy may be issued to the head of a family, who for this purpose may be the husband or the wife and who...

...iary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy. The insurer may at its option omit from the provision in division (L) of this section the following: Unless the insured makes an irrevocable designation of beneficiary. (M) A provision, which shall be contained in the policy or in an indor...

...ly a specified accident, accident only, credit, dental, disability income, long-term care, hospital indemnity, supplemental coverage as described in section 3923.37 of the Revised Code, specified disease, or vision care; a dental benefit that is offered as a part of a policy of sickness and accident insurance or a public employee benefit plan; coverage issued as a supplement to liability insurance; insurance arising ...

...the matters set forth in this section unless such provisions are in the words in which the same appear in this section. Any such provisions in any such policy shall be preceded by the appropriate caption appearing in this section or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the superintendent of insurance may approve. (A) A provision as follows: Change of occu...

...all not be wholly or partly unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom such policy is offered, delivered, or issued. As used in sections 3923.01, 3923.04, 3923.05, 3923.06, 3923.07, 3923.10, 3923.13, 3923.15, 3923.19 and 3923.20 of the Revised Code, "insured" shall not be construed as preventing a person other than the insured with a proper insurable interest from making ap...