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The Legislative Service Commission staff updates the Revised Code on an ongoing basis, as it completes its act review of enacted legislation. Updates may be slower during some times of the year, depending on the volume of enacted legislation.

Section 1751.79 | Utilization review program requirements.


A health insuring corporation that conducts utilization review shall prepare a written utilization review program that describes all review activities, both delegated and nondelegated, for covered health care services provided, including the following:

(A) Procedures to evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services;

(B) The use of data sources and clinical review criteria in making decisions;

(C) Mechanisms to ensure consistent application of criteria and compatible decisions;

(D) Data collection processes and analytical methods used in assessing utilization of health care services;

(E) Mechanisms for assuring confidentiality of clinical and proprietary information;

(F) The periodic assessment of utilization review activities, and the reporting of these assessments to the health insuring corporation's board, by a utilization review committee, a quality assurance committee, or any similar committee;

(G) The functional responsibility for day-to-day program management by staff;

(H) Defined methods by which guidelines are approved and communicated to providers and health care facilities.

Available Versions of this Section