Ohio Revised Code Search

...As used in this section and sections 3901.381 to 3901.3814 of the Revised Code: (A) "Beneficiary" means any policyholder, subscriber, member, employee, or other 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 ag...

...Beginning six months after the date 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 pursua...

...(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...

...(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...

...Sections 3901.38 and 3901.381 to 3901.3813 of the Revised Code do not apply to the following: (A) Policies offering coverage that is regulated under Chapters 3935. and 3937. of the 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 applicatio...

...(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...

...(A) As used in sections 3901.45 and 3901.46 of the Revised Code: (1) "AIDS," "HIV," "AIDS-related condition," and "HIV test" have the same meanings as in section 3701.24 of the Revised Code. (2) "Insurer" means any person authorized to engage in the business 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 ...

...As used in sections 3901.51 to 3901.55 of the Revised Code: (A) "Clearing corporation" has the same meaning as in section 1308.01 of the Revised Code, except that with respect to securities issued by institutions organized or existing under the laws of any foreign country or securities used to meet the deposit requirements pursuant to the laws of a foreign country as a condition of doing business in that country, "c...

...(A) An insurance company may place or arrange for the placement of securities held in or purchased for its general account and its separate accounts in a clearing corporation or the federal reserve book-entry system. Ownership of, and other interest in, these securities may be transferred by bookkeeping entry on the books of the clearing corporation or in the federal reserve book-entry system without physical deliver...

...No insurance company shall use, for any purpose other than to satisfy the deposit requirements under provisions of the insurance laws of this state, securities that have been placed in a clearing corporation or in the federal reserve book-entry system for the satisfaction of these requirements pursuant to division (B) of section 3901.53 of the Revised Code.

...An insurer may offer a wellness or health improvement program that provides rewards or incentives, including merchandise; gift cards; debit cards; premium discounts or rebates; contributions to a health savings account; modifications to copayment, deductible, or coinsurance amounts; or any combination of these incentives, to encourage participation or to reward participation in the program. A wellness or health im...

...As used in sections 3901.61 to 3901.65 of te Revised Code: (A) "Assuming insurer" means an insurance company that accepts all or part of the risk underwritten by a ceding insurer. (B) "Ceding insurer" means an insurance company that transfers all or part of the risk it underwrites to an assuming insurer.

...As used in sections 3901.67 to 3901.70 of the Revised Code: (A) "Material acquisition" means an acquisition, or a series of related acquisitions during any thirty-day period, that is nonrecurring and not in the ordinary course of business and involves more than five per cent of the reporting insurer's total admitted assets as reported in its most recent statutory financial statement filed with the department of insu...

...Sections 3901.67 to 3901.70 of the Revised Code apply to all of the following: (A) Asset acquisitions, including every purchase, lease, exchange, merger, consolidation, succession, or other acquisition other than the construction or development of real property by or for the reporting insurer, or the acquisition of materials for such purpose. (B) Asset dispositions, including every sale, lease, exchange, merger, co...

...The department of insurance shall forward a copy of any written notice received from any insurance company or health insuring corporation domiciled in this state that the insurer or health insuring corporation will be late in making the filing of any quarterly or annual financial statement, required under Title XXXIX or Chapter 1751. of the Revised Code, to the board of directors of the insurer or health insuring cor...

...As used in this section and sections 3901.811 to 3901.815 of the Revised Code: (A) "Auditing entity" means any person or government entity that performs a pharmacy audit, including a payer, a pharmacy benefit manager, or a third-party administrator licensed under Chapter 3959. of the Revised Code. (B) "Business day" means any day of the week excluding Saturday, Sunday, and a legal holiday, as defined in section 1.1...

...(A) Except as provided in division (B) of this section, an auditing entity is subject to all of the following conditions when performing a pharmacy audit in this state: (1) If it is necessary that the pharmacy audit be performed on the premises of a pharmacy, the auditing entity shall give the pharmacy that is the subject of the audit written notice of the date or dates on which the audit will be performed and the ...

...A pharmacy may do any of the following when a pharmacy audit is performed: (A) Validate a pharmacy record by using original or photocopied records from hospitals, physicians, or other health care providers; (B) Validate one or more claims for payment for the provision of dangerous drugs or pharmacy services by using either of the following: (1) An original pharmacy record or photocopy of the record; (2) An origin...

...(A) Except as provided in division (B) of this section, all of the following apply after a pharmacy audit is completed: (1) A pharmacy shall be given not less than thirty days from the date of the on-site audit to provide the auditing entity any additional information necessary to complete the preliminary audit report. (2) Not later than sixty business days after the audit is completed, the auditing entity shall de...

...Each auditing entity in this state shall establish in writing separate procedures for a pharmacy to appeal one or more findings in a preliminary audit report issued under section 3901.813 of the Revised Code.