As Introduced 1
122nd General Assembly 4
Regular Session H. B. No. 361 5
1997-1998 6
REPRESENTATIVES VAN VYVEN-TAVARES-BENDER-BOYD-BRADING-CAREY- 8
CLANCY-CORBIN-COUGHLIN-FORD-GARCIA-GERBERRY-HOTTINGER-KRUPINSKI- 9
LAWRENCE-MAIER-MILLER-MOTTLEY-O'BRIEN-OLMAN-OPFER- 10
PADGETT-PERZ-SALERNO-SAWYER-SCHULER-SCHURING-STAPLETON- 11
TAYLOR-TERWILLEGER-TIBERI-VESPER-WACHTMANN-WISE-ROMAN 11/1
14
A B I L L
To enact sections 1753.01, 1753.03, 1753.04, 16
1753.06, 1753.09, 1753.11 to 1753.13, 1753.15, 17
1753.21, 1753.22, 1753.24, 1753.26, 1753.28, 18
1753.30, 1753.36, 1753.38 to 1753.40, 1753.43, 19
1753.44, 1753.46 to 1753.49, 1753.51, 1753.66 to 20
1753.73, 1753.75, and 1753.81 of the Revised 21
Code to adopt the Physician-Health Plan 22
Partnership Act. 23
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 25
Section 1. That sections 1753.01, 1753.03, 1753.04, 27
1753.06, 1753.09, 1753.11, 1753.12, 1753.13, 1753.15, 1753.21, 28
1753.22, 1753.24, 1753.26, 1753.28, 1753.30, 1753.36, 1753.38, 30
1753.39, 1753.40, 1753.43, 1753.44, 1753.46, 1753.47, 1753.48,
1753.49, 1753.51, 1753.66, 1753.67, 1753.68, 1753.69, 1753.70, 31
1753.71, 1753.72, 1753.73, 1753.75, and 1753.81 of the Revised 33
Code be enacted to read as follows: 34
Sec. 1753.01. AS USED IN SECTIONS 1753.01 TO 1753.51 AND 36
1753.81 OF THE REVISED CODE: 38
(A) "HEALTH CARE PLAN" MEANS A CORPORATION THAT, PURSUANT 41
TO A POLICY, CONTRACT, CERTIFICATE, OR AGREEMENT, PAYS FOR, 42
REIMBURSES, OR PROVIDES, DELIVERS, ARRANGES FOR, OR OTHERWISE 43
MAKES AVAILABLE, MEDICAL TREATMENT OR OTHER HEALTH CARE SERVICES 44
2
BY A PHYSICIAN OR OTHER HEALTH CARE PROVIDER THROUGH EITHER AN 45
OPEN PANEL PLAN OR A CLOSED PANEL PLAN, IN EXCHANGE FOR A PREMIUM 46
RATE.
(B) "PHYSICIAN" MEANS ANY PERSON AUTHORIZED UNDER CHAPTER 50
4731. OF THE REVISED CODE TO PRACTICE MEDICINE AND SURGERY OR 53
OSTEOPATHIC MEDICINE AND SURGERY.
Sec. 1753.03. THE SUPERINTENDENT OF INSURANCE SHALL, IN 55
RULES ADOPTED BY THE SUPERINTENDENT IN ACCORDANCE WITH CHAPTER 57
119. OF THE REVISED CODE, PRESCRIBE A STANDARD CREDENTIALING FORM 60
TO BE USED BY ALL HEALTH CARE PLANS WHEN CREDENTIALING 61
PHYSICIANS. IN DEVELOPING THAT FORM, THE SUPERINTENDENT SHALL
TAKE INTO CONSIDERATION THE STANDARD CREDENTIALING FORMS 62
DEVELOPED BY THE NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS, 63
THE AMERICAN MEDICAL ASSOCIATION, THE AMERICAN ASSOCIATION OF 64
HEALTH PLANS, AND ANY OTHER NATIONAL ORGANIZATION THAT HAS 65
DEVELOPED SUCH A FORM.
Sec. 1753.04. BEGINNING NINETY DAYS AFTER RULES ADOPTED 67
UNDER SECTION 1753.03 OF THE REVISED CODE TAKE EFFECT, NO HEALTH 70
CARE PLAN SHALL FAIL TO USE THE STANDARD CREDENTIALING FORM 71
PRESCRIBED IN THOSE RULES OR IN ANY AMENDMENT TO THOSE RULES WHEN 73
INITIALLY CREDENTIALING OR RECREDENTIALING PHYSICIANS.
A HEALTH CARE PLAN MAY REQUEST ADDITIONAL INFORMATION FROM 75
A PHYSICIAN AS NECESSARY TO COMPLY WITH THE PLAN'S CREDENTIALING 76
STANDARDS. 77
Sec. 1753.06. (A) AS USED IN THIS SECTION: 80
(1) "ECONOMIC PROFILING" MEANS THE USE OF ECONOMIC 82
PERFORMANCE DATA AND ECONOMIC INFORMATION IN DETERMINING A 83
PHYSICIAN'S QUALIFICATION TO PARTICIPATE IN A HEALTH CARE PLAN. 85
(2) "GROUP OF HEALTH CARE PROVIDERS" MEANS AN 87
ORGANIZATION, PARTNERSHIP, OR OTHER ASSOCIATION OF TWO OR MORE 88
PHYSICIANS OR OTHER LICENSED HEALTH CARE PROVIDERS THAT HAS 89
CONTRACTED TO PROVIDE HEALTH CARE SERVICES TO ENROLLEES OF A 90
HEALTH CARE PLAN, EITHER DIRECTLY WITH THE PLAN OR INDIRECTLY 91
THROUGH A GROUP OF HEALTH CARE PROVIDERS. 92
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(B) A HEALTH CARE PLAN OR GROUP OF HEALTH CARE PROVIDERS 95
MAY USE ECONOMIC PROFILING AS A FACTOR IN CREDENTIALING A 96
PHYSICIAN ONLY IF THE ECONOMIC PROFILING TAKES INTO CONSIDERATION 97
THE CASE MIX, SEVERITY OF ILLNESS, AND AGE OF PATIENTS. 98
(C) FOR AN INITIAL APPLICANT, A HEALTH CARE PLAN MAY 101
REQUEST INFORMATION NECESSARY TO PERFORM AN ECONOMIC PROFILE. IF 102
A PHYSICIAN DOES NOT PROVIDE INFORMATION REQUESTED BY THE HEALTH 103
CARE PLAN OR GROUP OF HEALTH CARE PROVIDERS THAT ENABLES IT TO 104
TAKE INTO CONSIDERATION CASE MIX, SEVERITY OF ILLNESS, AND AGE OF 105
PATIENTS, THE PLAN IS NOT REQUIRED TO TAKE THESE FACTORS INTO 106
CONSIDERATION IN ITS ECONOMIC PROFILE OF THE PHYSICIAN. 107
(D) NOTHING IN THIS SECTION PROHIBITS A HEALTH CARE PLAN 110
OR GROUP OF HEALTH CARE PROVIDERS FROM TAKING INTO CONSIDERATION 111
THE QUALITY AND APPROPRIATENESS OF CARE PROVIDED BY A PHYSICIAN 112
WHEN DECIDING WHETHER TO EMPLOY, CONTRACT WITH, OR TERMINATE THE 113
PHYSICIAN. 114
Sec. 1753.09. A HEALTH CARE PLAN SHALL NOTIFY A PHYSICIAN 116
OF THE STATUS OF THE PHYSICIAN'S APPLICATION WITHIN ONE HUNDRED 117
TWENTY DAYS AFTER THE PLAN'S RECEIPT OF THE COMPLETED 118
APPLICATION. THAT TIME PERIOD MAY BE EXTENDED BY THE PLAN IF, 119
DUE TO EXTENUATING CIRCUMSTANCES, THE PLAN NEEDS ADDITIONAL TIME 120
TO CONSIDER THE APPLICATION AND IT NOTIFIES THE PHYSICIAN OF THE 121
REASON FOR THE DELAY. 122
Sec. 1753.11. (A) PRIOR TO ENTERING INTO A PARTICIPATION 125
CONTRACT WITH A PHYSICIAN, A HEALTH CARE PLAN SHALL, UPON 126
REQUEST, DISCLOSE BASIC INFORMATION REGARDING ITS PROGRAMS AND 127
PROCEDURES TO THE PHYSICIAN. THE INFORMATION SHALL INCLUDE ALL 128
OF THE FOLLOWING:
(1) HOW A PHYSICIAN IS REIMBURSED FOR THE PHYSICIAN'S 130
SERVICES, AND THE AMOUNT OF THE REIMBURSEMENT; 131
(2) WHETHER ANY REINSURANCE PROTECTION IS PROVIDED OR IS 133
MADE AVAILABLE; 134
(3) WHETHER THE PLAN CHARGES ANY ADMINISTRATIVE, 136
OPERATIONS, OR MEMBERSHIP FEES, WHAT THE PURPOSE IS FOR THE FEES, 138
4
AND HOW FREQUENTLY THE FEES ARE COLLECTED;
(4) THE OUT-OF-POCKET COSTS FOR ENROLLEES, AND WHAT 140
PROCEDURES A PHYSICIAN MUST FOLLOW TO COLLECT THEM, IF 141
APPLICABLE; 142
(5) THE PROCEDURES THAT MUST BE FOLLOWED IN ORDER TO 144
SUBMIT A COMPLETED CLAIM, INCLUDING THE TIME WITHIN WHICH A CLAIM 146
MUST BE SUBMITTED;
(6) INFORMATION REGARDING QUALITY IMPROVEMENT PROGRAMS AND 149
ANY REQUIREMENTS IMPOSED ON PARTICIPATING PHYSICIANS;
(7) INFORMATION REGARDING UTILIZATION REVIEW PROGRAMS, 151
INCLUDING THE CRITERIA USED IN CONDUCTING UTILIZATION REVIEW, THE 153
RESOURCES USED TO DETERMINE THE APPROPRIATE UTILIZATION OF
SERVICES, THE PARTIES RESPONSIBLE FOR UTILIZATION REVIEW 154
DECISIONS, AND THE AVAILABILITY OF AN APPEAL PROCESS FOR ADVERSE 155
UTILIZATION REVIEW DECISIONS; 156
(8) ANY PENALTIES OR SANCTIONS FOR NONCOMPLIANCE WITH THE 158
PLAN'S HEALTH CARE SERVICE UTILIZATION PROTOCOLS OR PROGRAMS; 160
(9) HOW REFERRALS TO OTHER PARTICIPATING PHYSICIANS OR TO 162
NONPARTICIPATING PHYSICIANS ARE MADE; 163
(10) WHETHER PHYSICIANS ARE REQUIRED TO BE AVAILABLE TO 165
ENROLLEES AT CERTAIN TIMES, AND ANY LIMITATIONS ON THE SELECTION 166
OF A PHYSICIAN TO TREAT ENROLLEES ON A PHYSICIAN'S BEHALF WHEN 167
THE PHYSICIAN IS UNAVAILABLE; 168
(11) THE AVAILABILITY OF DISPUTE RESOLUTION PROCEDURES AND 171
THE POTENTIAL FOR COST TO BE INCURRED;
(12) THE LEVELS OF PROFESSIONAL LIABILITY INSURANCE 173
REQUIRED FOR PARTICIPATING PHYSICIANS; 174
(13) HOW A PHYSICIAN'S NAME AND ADDRESS WILL BE USED IN 176
MARKETING MATERIALS; 177
(14) HOW A CONTRACT MAY BE AMENDED, WHETHER A PHYSICIAN 179
MAY OBJECT TO A CONTRACT AMENDMENT, WHETHER AMENDMENTS MAY BE 180
MADE TO DOCUMENTS INCORPORATED BY REFERENCE INTO THE CONTRACT, 181
AND WHETHER AN OPPORTUNITY TO OBJECT TO SUCH CHANGES WILL BE 182
GRANTED; 183
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(15) UNDER WHAT CIRCUMSTANCES EITHER PARTY CAN TERMINATE 185
THE CONTRACT, WHAT OPPORTUNITY IS AFFORDED A PARTICIPATING 186
PHYSICIAN TO REQUEST RECONSIDERATION OF A TERMINATION DECISION, 187
AND WHAT OBLIGATIONS EXIST FOR A PHYSICIAN UPON TERMINATION. 189
(B) A HEALTH CARE PLAN SHALL PROVIDE ALL OF THE FOLLOWING 192
TO A PARTICIPATING PHYSICIAN: 193
(1) ANY MATERIAL INCORPORATED BY REFERENCE INTO THE 195
PARTICIPATION CONTRACT; 196
(2) ADMINISTRATIVE MANUALS RELATED TO PHYSICIAN 198
PARTICIPATION, IF ANY; 199
(3) A SIGNED AND DATED COPY OF THE FINAL PARTICIPATION 201
CONTRACT. 202
Sec. 1753.12. (A) A HEALTH CARE PLAN SHALL NOTIFY A 205
PHYSICIAN PRIOR TO AMENDING THE PHYSICIAN'S PARTICIPATION 206
CONTRACT WITH THE PLAN, OR AMENDING ANY DOCUMENT INCORPORATED BY 207
REFERENCE INTO THE CONTRACT, IF THE AMENDMENT AFFECTS 208
PARTICIPATING PHYSICIANS. SUCH AN AMENDMENT IS NOT EFFECTIVE 209
UNTIL A PHYSICIAN HAS HAD REASONABLE TIME, AS DEFINED IN THE
CONTRACT, TO EXERCISE THE PHYSICIAN'S RIGHT TO TERMINATE 210
PARTICIPATION STATUS IN ACCORDANCE WITH THE TERMS AND CONDITIONS 211
OF THE CONTRACT. 212
(B) DIVISION (A) OF THIS SECTION DOES NOT APPLY IF THE 216
DELAY CAUSED BY COMPLIANCE WITH THAT DIVISION COULD RESULT IN 217
IMMINENT HARM TO AN ENROLLEE OR IF THE AMENDMENT IS REQUIRED BY 218
STATE OR FEDERAL LAW, RULE, OR REGULATION.
Sec. 1753.13. (A) NO HEALTH CARE PLAN OR ANY OF ITS 221
CONTRACTING ENTITIES SHALL INCLUDE, IN ANY CONTRACT ENTERED INTO 222
WITH A PHYSICIAN, ANY PROVISION THAT LIMITS OR OTHERWISE 223
RESTRICTS THE PHYSICIAN'S ETHICAL AND LEGAL RESPONSIBILITY TO 224
FULLY ADVISE PATIENTS ABOUT THEIR MEDICAL CONDITION AND THE 225
MEDICALLY APPROPRIATE TREATMENT OPTIONS. 226
(B) NO HEALTH CARE PLAN SHALL TERMINATE EMPLOYMENT OR ANY 229
OTHER CONTRACTUAL RELATIONSHIP WITH, OR OTHERWISE PENALIZE, A 230
PHYSICIAN PRINCIPALLY FOR ADVOCATING FOR MEDICALLY APPROPRIATE 231
6
HEALTH CARE.
(C) THIS SECTION SHALL NOT BE CONSTRUED AS PROHIBITING A 234
HEALTH CARE PLAN FROM DOING EITHER OF THE FOLLOWING: 235
(1) MAKING A DETERMINATION NOT TO REIMBURSE OR PAY FOR A 237
PARTICULAR MEDICAL TREATMENT OR OTHER HEALTH CARE SERVICE; 239
(2) ENFORCING REASONABLE PEER REVIEW OR UTILIZATION REVIEW 242
PROTOCOLS, OR DETERMINING WHETHER A PHYSICIAN HAS COMPLIED WITH 243
THOSE PROTOCOLS.
Sec. 1753.15. (A) EXCEPT AS PROVIDED IN DIVISION (D) OF 245
THIS SECTION, PRIOR TO TERMINATING A CONTRACT WITH A PHYSICIAN ON 246
THE BASIS OF THE PHYSICIAN'S DELIVERY OF HEALTH CARE SERVICES, A 248
HEALTH CARE PLAN SHALL GIVE THE PHYSICIAN NOTICE OF THE REASON OR 249
REASONS FOR ITS DECISION TO TERMINATE AND AN OPPORTUNITY TO TAKE 250
CORRECTIVE ACTION. THE PLAN SHALL DEVELOP A CORRECTIVE ACTION 251
PLAN IN CONJUNCTION WITH THE PHYSICIAN. IF, AFTER BEING AFFORDED 252
THE OPPORTUNITY TO TAKE CORRECTIVE ACTION, THE PHYSICIAN FAILS TO 253
DO SO, THE PLAN MAY TERMINATE THE CONTRACT. 254
(B)(1) A PHYSICIAN WHOSE CONTRACT HAS BEEN TERMINATED 257
UNDER DIVISION (A) OF THIS SECTION MAY APPEAL THE TERMINATION TO 259
THE APPROPRIATE MEDICAL DIRECTOR OF THE PLAN. THE MEDICAL 260
DIRECTOR SHALL GIVE THE PHYSICIAN AN OPPORTUNITY TO DISCUSS WITH 261
THE MEDICAL DIRECTOR THE REASON OR REASONS FOR THE TERMINATION. 262
(2) IF A SATISFACTORY RESOLUTION CANNOT BE REACHED, THE 264
PHYSICIAN MAY APPEAL THE TERMINATION DECISION TO A PANEL COMPOSED 266
OF PHYSICIANS WHO ARE UNDER CONTRACT WITH THE HEALTH CARE PLAN 267
AND WHO HAVE COMPARABLE OR HIGHER LEVELS OF EDUCATION AND 268
TRAINING THAN THE PHYSICIAN. A REPRESENTATIVE OF THE PHYSICIAN'S 269
SPECIALTY SHALL BE A MEMBER OF THE PANEL, IF POSSIBLE. 270
THE PANEL SHALL RENDER ITS DECISION TO THE PHYSICIAN AND TO 273
THE MEDICAL DIRECTOR WITHIN THIRTY DAYS AFTER HOLDING A HEARING 274
ON THE MATTER.
(3) THE MEDICAL DIRECTOR SHALL REVIEW AND CONSIDER THE 276
PANEL'S DETERMINATION BEFORE MAKING A DECISION. THE DECISION 277
RENDERED BY THE MEDICAL DIRECTOR IS FINAL. 278
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(C) A PHYSICIAN'S CONTRACT SHALL REMAIN IN EFFECT DURING 281
THE APPEAL PROCESS SET FORTH IN DIVISION (B) OF THIS SECTION 283
UNLESS THE TERMINATION WAS BASED ON ANY OF THE REASONS LISTED IN 284
DIVISION (D) OF THIS SECTION. 285
(D) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A 287
PHYSICIAN'S CONTRACT MAY BE TERMINATED AT ANY TIME WITHOUT NOTICE 288
IF EVIDENCE EXISTS OF IMMINENT RISK OF HARM TO AN ENROLLEE OR 289
ENROLLEES BASED UPON A FINDING OF UNACCEPTABLE QUALITY OF CARE, 290
FRAUD, PATIENT ABUSE, LOSS OF CLINICAL PRIVILEGES, LOSS OF 291
PROFESSIONAL LIABILITY COVERAGE IF THE CONTRACT REQUIRES SUCH 292
COVERAGE, INCOMPETENCE, LOSS OF AUTHORITY TO PRACTICE MEDICINE 293
AND SURGERY OR OSTEOPATHIC MEDICINE AND SURGERY UNDER CHAPTER 295
4731. OF THE REVISED CODE, OR A GOVERNMENTAL ACTION HAS IMPAIRED 296
THE PHYSICIAN'S ABILITY TO PRACTICE.
(E)(1) NOTHING IN THIS SECTION PROHIBITS A HEALTH CARE 299
PLAN OR GROUP OF HEALTH CARE PROVIDERS FROM REJECTING A 300
PHYSICIAN'S APPLICATION FOR PARTICIPATION ON A PANEL, OR 301
TERMINATING A PHYSICIAN'S PARTICIPATION ON A PANEL, IF THE PLAN 302
DETERMINES THAT THE PLAN IS MEETING THE HEALTH CARE NEEDS OF ITS 303
ENROLLEES AND NO ADDITIONAL NEED EXISTS IN ITS PROVIDER NETWORK 304
FOR THE PHYSICIAN'S SERVICES. 305
(2) NOTHING IN THIS SECTION REQUIRES A HEALTH CARE PLAN OR 308
A GROUP OF HEALTH CARE PROVIDERS TO EMPLOY OR CONTRACT WITH ANY 309
PARTICULAR CATEGORY OF HEALTH CARE PROVIDER OR HEALTH CARE
FACILITY. 310
Sec. 1753.21. (A) EACH HEALTH CARE PLAN SHALL PROVIDE TO 313
ENROLLEES AND PURCHASERS AN EVIDENCE OF COVERAGE THAT INCLUDES 315
ALL OF THE FOLLOWING INFORMATION: 316
(1) THE PLAN STRUCTURE; 318
(2) THE BENEFITS COVERED AND EXCLUDED BY THE PLAN; 320
(3) PROCEDURES GOVERNING OUT-OF-AREA COVERAGE; 322
(4) ENROLLEE COST-SHARING REQUIREMENTS; 324
(5) ANY PRIOR APPROVAL REQUIREMENTS FOR OBTAINING 326
PRESCRIPTION DRUGS; 327
8
(6) HOW AN ENROLLEE OBTAINS PREVENTIVE HEALTH SERVICES AND 330
HEALTH EDUCATION PROVIDED BY THE PLAN;
(7) HOW AN ENROLLEE OBTAINS MEDICALLY NECESSARY COVERAGE, 332
EMERGENCY CARE COVERAGE, OUT-OF-AREA EMERGENCY CARE, AND URGENT 333
CARE SERVICES; 334
(8) IF REQUIRED, HOW AN ENROLLEE SELECTS A PRIMARY CARE 336
PHYSICIAN, AND THE PROCESS BY WHICH AN ENROLLEE CHANGES THAT 337
SELECTION; 338
(9) THE PLAN'S UTILIZATION REVIEW PROCEDURES, INCLUDING 340
THE PROCEDURES FOR OBTAINING REVIEW OF ADVERSE DETERMINATIONS AND 342
A STATEMENT OF THE RIGHTS AND RESPONSIBILITIES OF ENROLLEES WITH 343
RESPECT TO THOSE PROCEDURES;
(10) THE REVIEW PROCEDURES USED TO DETERMINE COVERAGE OF 345
INVESTIGATIONAL OR EXPERIMENTAL TREATMENTS; 346
(11) IF APPLICABLE, PLAN UTILIZATION OF VOLUNTARY OR 348
MANDATORY ARBITRATION OR DISPUTE RESOLUTION PROCEDURES; 349
(12) HOW TO FILE A GRIEVANCE AGAINST THE PLAN; 351
(13) A STATEMENT THAT THE INFORMATION LISTED IN DIVISION 353
(C) OF THIS SECTION IS AVAILABLE FROM THE PLAN UPON REQUEST. 354
(B) A HEALTH CARE PLAN SHALL, UPON REQUEST, PROVIDE TO A 356
PROSPECTIVE ENROLLEE OR PROSPECTIVE PURCHASER A SUMMARY OF ANY OF 357
THE INFORMATION INCLUDED IN THE PLAN'S EVIDENCE OF COVERAGE. THE 358
SUMMARY SHALL INCLUDE A STATEMENT THAT THE INFORMATION LISTED IN 359
DIVISION (C) OF THIS SECTION IS AVAILABLE FROM THE PLAN UPON 360
REQUEST.
(C) A HEALTH CARE PLAN SHALL, UPON REQUEST, PROVIDE TO A 363
PROSPECTIVE ENROLLEE, PROSPECTIVE PURCHASER, ENROLLEE, OR 364
PURCHASER ANY OF THE FOLLOWING INFORMATION: 365
(1) THE QUALITY AND SATISFACTION ASSESSMENTS USED BY THE 367
PLAN, INCLUDING THE CURRENT RESULTS OF THE ASSESSMENTS; 368
(2) A DESCRIPTION OF THE PLAN'S QUALITY IMPROVEMENT 370
PROGRAM; 371
(3) IF APPLICABLE, INFORMATION ON LOCATIONS AND HOURS OF 373
OPERATION OF THE MEDICAL OFFICES, HOSPITALS, AND ALL OTHER 374
9
FACILITIES OWNED BY THE PLAN AT WHICH THE ENROLLEE CAN OBTAIN 375
COVERED HEALTH CARE SERVICES; 376
(4) A DESCRIPTION OF THE TYPE OF FINANCIAL RISK 378
ARRANGEMENTS, INCLUDING BUT NOT LIMITED TO CAPITATION, FINANCIAL 379
INCENTIVES OR BONUSES, FEE-FOR-SERVICE, SALARY, AND WITHHOLDINGS, 380
UNDER WHICH THE PLAN'S PHYSICIANS PROVIDE HEALTH CARE SERVICES. 381
NOTHING IN DIVISION (C)(4) OF THIS SECTION SHALL BE CONSTRUED AS 383
REQUIRING HEALTH CARE PLANS TO DISCLOSE PROPRIETARY INFORMATION, 384
INCLUDING, BUT NOT LIMITED TO, REIMBURSEMENT AMOUNTS TO 385
INDIVIDUAL PROVIDERS OR FACILITIES.
(5) THE CURRENT LIST OF THE PLAN'S PARTICIPATING PROVIDERS 388
WITHIN THE ENROLLEE'S GEOGRAPHIC SERVICE AREA. THE LIST SHALL 389
INCLUDE AT LEAST THE FOLLOWING INFORMATION FOR EACH SUCH
PROVIDER: 390
(a) THE DEGREE OBTAINED; 392
(b) THE PRACTICE SPECIALTY; 394
(c) PRACTICE LOCATION, INCLUDING ADDRESS AND TELEPHONE 397
NUMBER.
(6) INFORMATION REGARDING FORMULARY INCLUSION OR EXCLUSION 400
OF A PARTICULAR DRUG OR THERAPEUTIC CLASS OF DRUGS; 401
(7) A LOCAL OR TOLL-FREE TELEPHONE NUMBER TO CALL TO 403
OBTAIN ADDITIONAL INFORMATION ABOUT THE PLAN AND ITS OPERATIONS. 405
(D) ALL OF THE INFORMATION DISCLOSED BY A HEALTH CARE PLAN 408
PURSUANT TO THIS SECTION SHALL BE ACCURATE AND CURRENT, AND SHALL 409
BE PROVIDED IN A MANNER THAT MEETS THE READABILITY REQUIREMENT 410
SET FORTH IN DIVISION (A)(1) OF SECTION 3902.04 OF THE REVISED 411
CODE.
Sec. 1753.22. EACH HEALTH CARE PLAN SHALL ESTABLISH A 413
SYSTEM THAT ENABLES AN ENROLLEE'S ELIGIBILITY TO RECEIVE COVERED 414
HEALTH CARE SERVICES FROM A PHYSICIAN OR HEALTH CARE FACILITY, 415
AND THE PARTICIPATING STATUS OF A PHYSICIAN OR FACILITY, TO BE 416
VERIFIED AT ANY TIME THE PHYSICIAN OR FACILITY IS OBLIGATED TO 417
PROVIDE OR ARRANGE FOR THE PROVISION OF COVERED HEALTH CARE 418
SERVICES, INCLUDING TIMES OTHER THAN DURING THE PLAN'S NORMAL 419
10
BUSINESS HOURS. 420
Sec. 1753.24. (A) A HEALTH CARE PLAN SHALL ESTABLISH AND 423
IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE MAY RECEIVE A STANDING 424
REFERRAL TO A SPECIALIST. THE PROCEDURE SHALL PROVIDE FOR A 425
STANDING REFERRAL TO A SPECIALIST IF THE PRIMARY CARE PHYSICIAN 426
DETERMINES IN CONSULTATION WITH THE SPECIALIST, IF ANY, THAT AN 427
ENROLLEE NEEDS CONTINUING CARE FROM A SPECIALIST. THE REFERRAL 429
SHALL BE MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE PLAN 430
IN CONSULTATION WITH THE PRIMARY CARE PHYSICIAN, THE SPECIALIST, 431
AND THE ENROLLEE. THE TREATMENT PLAN MAY LIMIT THE NUMBER OF 432
VISITS TO THE SPECIALIST, LIMIT THE PERIOD OF TIME THAT THE 433
VISITS ARE AUTHORIZED, OR REQUIRE THAT THE SPECIALIST PROVIDE THE 434
PRIMARY CARE PHYSICIAN WITH REGULAR REPORTS ON THE HEALTH CARE 435
PROVIDED TO THE ENROLLEE.
(B) A HEALTH CARE PLAN SHALL ESTABLISH AND IMPLEMENT A 438
PROCEDURE BY WHICH AN ENROLLEE WITH A CONDITION OR DISEASE THAT 439
REQUIRES SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME
AND IS LIFE-THREATENING, DEGENERATIVE, OR DISABLING MAY RECEIVE A 440
REFERRAL TO A SPECIALIST WHO HAS EXPERTISE IN TREATING THE 441
CONDITION OR DISEASE FOR THE PURPOSE OF HAVING THE SPECIALIST 442
COORDINATE THE ENROLLEE'S HEALTH CARE. THE REFERRAL SHALL BE 444
MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE HEALTH CARE 445
PLAN IN CONSULTATION WITH THE PRIMARY CARE PHYSICIAN, SPECIALIST, 446
AND ENROLLEE. AFTER THE REFERRAL IS MADE, THE SPECIALIST SHALL 447
BE AUTHORIZED TO PROVIDE HEALTH CARE SERVICES TO THE ENROLLEE IN 448
THE SAME MANNER AS THE ENROLLEE'S PRIMARY CARE PHYSICIAN, SUBJECT 450
TO THE TERMS OF THE TREATMENT PLAN.
(C) THE DETERMINATIONS DESCRIBED IN DIVISIONS (A) AND (B) 453
OF THIS SECTION SHALL BE MADE WITHIN SEVENTY-TWO HOURS AFTER A 454
REQUEST FOR THE DETERMINATION IS MADE BY THE ENROLLEE OR THE 455
ENROLLEE'S PRIMARY CARE PHYSICIAN AND ALL APPROPRIATE MEDICAL 456
RECORDS AND OTHER ITEMS OF INFORMATION NECESSARY TO MAKE THE 457
DETERMINATION ARE PROVIDED. ONCE A DETERMINATION IS MADE, THE 458
REFERRAL SHALL BE MADE WITHIN NINETY-SIX HOURS AFTER THE 459
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DETERMINATION. 460
DIVISIONS (A) AND (B) OF THIS SECTION DO NOT REQUIRE A 464
HEALTH CARE PLAN TO PERMIT AN ENROLLEE TO ELECT REFERRAL TO A 465
SPECIALIST WHO IS NOT EMPLOYED BY OR UNDER CONTRACT WITH THE PLAN 466
TO PROVIDE HEALTH CARE SERVICES TO ITS ENROLLEES. 467
Sec. 1753.26. A HEALTH CARE PLAN OR UTILIZATION REVIEW 469
ORGANIZATION THAT AUTHORIZES A PROPOSED ADMISSION, TREATMENT, OR 470
SERVICE BY A PHYSICIAN BASED UPON THE TRUTHFUL SUBMISSION OF ALL 471
NECESSARY INFORMATION RELATIVE TO AN ELIGIBLE ENROLLEE SHALL NOT 472
RETROACTIVELY DENY THIS AUTHORIZATION IF THE PHYSICIAN RENDERS 473
THE HEALTH CARE SERVICE IN GOOD FAITH AND PURSUANT TO THE 474
AUTHORIZATION AND ALL OF THE TERMS AND CONDITIONS OF THE 475
PHYSICIAN'S CONTRACT WITH THE PLAN.
Sec. 1753.28. EACH EXPLANATION OF BENEFITS STATEMENT SENT 477
BY A HEALTH CARE PLAN TO AN ENROLLEE SHALL CONTAIN A CLEAR 480
EXPLANATION OF THE SERVICES RENDERED, THE AMOUNT PAID BY THE
PLAN, AND THE FINANCIAL OBLIGATIONS OF THE ENROLLEE, IF ANY. 482
Sec. 1753.30. EACH HEALTH CARE PLAN SHALL NOTIFY AFFECTED 484
ENROLLEES OF THE TERMINATION OF ANY CONTRACT WITH A PRIMARY CARE 485
PHYSICIAN OR HOSPITAL.
Sec. 1753.36. (A) IF A HEALTH CARE PLAN OR PHARMACY 487
BENEFIT MANAGEMENT PROVIDER IS USING A RESTRICTED FORMULARY OF 488
PRESCRIPTION DRUG PRODUCTS, THE HEALTH CARE PLAN SHALL DO BOTH OF 489
THE FOLLOWING:
(1) DEVELOP SUCH A FORMULARY IN CONSULTATION WITH AND 491
APPROVAL OF A PHARMACY AND THERAPEUTICS COMMITTEE, A MAJORITY OF 492
THE MEMBERS OF WHICH ARE PARTICIPATING PHYSICIANS OF THE HEALTH 493
CARE PLAN WHO MAY PRESCRIBE PRESCRIPTION DRUGS AND PARTICIPATING 495
PHARMACISTS OF THE PLAN, OR IN CONSULTATION WITH AND APPROVAL OF 496
A PHARMACY AND THERAPEUTICS COMMITTEE OF A PHARMACY BENEFIT
MANAGEMENT PROVIDER THAT IS INDEPENDENT OF THE HEALTH CARE PLAN, 497
CONSISTING OF PHYSICIANS WHO MAY PRESCRIBE PRESCRIPTION DRUGS IN 499
THEIR STATE OF LICENSURE AND PHARMACISTS WHO ARE AUTHORIZED TO 500
PRACTICE IN THEIR STATE OF LICENSURE.
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(2) ESTABLISH A PROCEDURE BY WHICH AN ENROLLEE MAY OBTAIN, 502
WITHOUT PENALTY OR ADDITIONAL COST SHARING BEYOND THAT PROVIDED 503
FOR FORMULARY DRUGS UNDER THE ENROLLEE'S CONTRACT WITH THE PLAN, 504
COVERAGE OF A SPECIFIC NONFORMULARY DRUG WHEN THE PRESCRIBER 505
DOCUMENTS IN THE ENROLLEE'S MEDICAL RECORD AND CERTIFIES THAT THE 506
FORMULARY ALTERNATIVE HAS BEEN INEFFECTIVE IN THE TREATMENT OF 507
THE ENROLLEE'S DISEASE OR CONDITION, OR THAT THE FORMULARY
ALTERNATIVE CAUSES OR IS REASONABLY EXPECTED BY THE PRESCRIBER TO 508
CAUSE A HARMFUL OR ADVERSE REACTION IN THE ENROLLEE. 509
(B) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE 511
A HEALTH CARE PLAN TO PLACE ANY PARTICULAR PHARMACEUTICAL PRODUCT 512
OR THERAPEUTIC CLASS OF PRODUCT ON ITS FORMULARY, OR TO PROHIBIT 513
A HEALTH CARE PLAN FROM RESTRICTING PAYMENT FOR ANY SPECIFIC 514
PHARMACEUTICAL PRODUCT OR THERAPEUTIC CLASS OF PRODUCT, 516
INCLUDING, BUT NOT LIMITED TO, BY REQUIRING THAT THE PRODUCT BE
PRESCRIBED ONLY BY A DEFINED SPECIALIST OR SUBSPECIALIST. 517
Sec. 1753.38. EACH HEALTH CARE PLAN SHALL ESTABLISH AN 519
INTERNAL TECHNOLOGY ASSESSMENT PROCESS FOR ASSESSING WHETHER A 520
DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY IS PROVEN TO BE SAFE 521
AND EFFICACIOUS FOR A PARTICULAR INDICATION OR CONDITION WHEN 522
COMPARED TO ALTERNATIVE THERAPIES, OR WHETHER IT REMAINS
EXPERIMENTAL OR INVESTIGATIONAL. THE PLAN'S INTERNAL TECHNOLOGY 523
ASSESSMENT PROCESS SHALL MEET ALL OF THE FOLLOWING CRITERIA: 524
(A) DECISIONS ARE MADE BY MEDICAL PROFESSIONALS, INCLUDING 526
PHYSICIANS. 527
(B) THE PROCESS INCLUDES A REVIEW OF RELEVANT MEDICAL 529
EVIDENCE, INCLUDING THE FOLLOWING, IF AVAILABLE: 530
(1) PEER-REVIEWED MEDICAL AND SCIENTIFIC LITERATURE ON THE 532
SUBJECT;
(2) PUBLISHED OPINIONS, ACTIONS, AND OTHER RELEVANT 534
DOCUMENTS OF INDEPENDENT, EXTERNAL RESEARCH ORGANIZATIONS SUCH AS 535
THE NATIONAL INSTITUTE OF HEALTH, THE NATIONAL CANCER INSTITUTE, 536
THE UNITED STATES FOOD AND DRUG ADMINISTRATION, AND THE AGENCY 537
FOR HEALTH CARE POLICY AND RESEARCH; 538
13
(3) PUBLISHED OPINIONS OF MEDICAL EXPERTS OR AFFECTED 540
SPECIALTY SOCIETIES.
(C) GENERAL COVERAGE DECISIONS, MADE PURSUANT TO THIS 542
PROCESS, THAT EXCLUDE DRUGS, DEVICES, PROCEDURES, OR OTHER 543
THERAPIES ON THE BASIS THAT THEY ARE NOT SAFE OR EFFICACIOUS AND 544
REMAIN EXPERIMENTAL OR INVESTIGATIONAL ARE REVIEWED AND UPDATED 545
AS NEW SCIENTIFIC EVIDENCE BECOMES AVAILABLE.
(D) A DESCRIPTION OF THE PLAN'S INTERNAL TECHNOLOGY 547
ASSESSMENT PROCESS IS MADE AVAILABLE TO PARTICIPATING PROVIDERS 548
AND ENROLLEES, UPON REQUEST. THE PLAN ALSO MAKES AVAILABLE, TO 549
PARTICIPATING PROVIDERS AND ENROLLEES, UPON REQUEST, A COPY OF 550
SPECIFIC COVERAGE POLICIES FOR SPECIFIC CONDITIONS OR TREATMENTS 551
IF SUCH POLICIES HAVE BEEN MADE PURSUANT TO THE PROCESS REQUIRED 552
BY THIS SECTION, WHEN THE ENROLLEE HAS BEEN DENIED COVERAGE FOR 553
THAT PARTICULAR CONDITION OR TREATMENT. SPECIFIC COVERAGE
POLICIES SHALL INCLUDE A DESCRIPTION OF THE EVIDENCE UPON WHICH 554
THE POLICY WAS BASED, AND SHALL CONTAIN THE DATE THE POLICY WAS 555
ADOPTED.
(E) IF THE PLAN HAS NOT CONDUCTED A TECHNOLOGY ASSESSMENT 557
FOR A PROPOSED THERAPY FOR A PARTICULAR PATIENT'S MEDICAL 558
CONDITION, AND THAT THERAPY MAY BE CONSIDERED EXPERIMENTAL OR 559
INVESTIGATIONAL, THE PLAN SHALL CONDUCT A TECHNOLOGY ASSESSMENT 560
OF THE PROPOSED THERAPY PURSUANT TO THIS SECTION OR USE THE 562
EXTERNAL, INDEPENDENT REVIEW PROCESS REQUIRED IN SECTION 1753.39
OF THE REVISED CODE. 563
Sec. 1753.39. (A) EACH HEALTH CARE PLAN SHALL ESTABLISH A 565
REASONABLE EXTERNAL, INDEPENDENT REVIEW PROCESS TO EXAMINE THE 566
PLAN'S COVERAGE DECISIONS FOR INDIVIDUAL ENROLLEES WHO MEET ALL 567
OF THE FOLLOWING CRITERIA:
(1) THE ENROLLEE HAS A TERMINAL CONDITION THAT, ACCORDING 569
TO THE CURRENT DIAGNOSIS OF THE ENROLLEE'S PHYSICIAN, HAS A HIGH 570
PROBABILITY OF CAUSING DEATH WITHIN TWO YEARS. 571
(2) THE ENROLLEE'S PHYSICIAN CERTIFIES THAT THE ENROLLEE 573
HAS THE CONDITION DESCRIBED IN DIVISION (A)(1) OF THIS SECTION, 574
14
FOR WHICH STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN IMPROVING 575
THE CONDITION OF THE ENROLLEE, OR FOR WHICH STANDARD THERAPIES 576
WOULD NOT BE MEDICALLY APPROPRIATE FOR THE ENROLLEE, OR FOR WHICH 577
THERE IS NO MORE BENEFICIAL STANDARD THERAPY COVERED BY THE PLAN 578
THAN THE THERAPY DESCRIBED IN DIVISION (A)(3) OF THIS SECTION. 579
(3) THE ENROLLEE'S PHYSICIAN HAS RECOMMENDED A DRUG, 581
DEVICE, PROCEDURE, OR OTHER THERAPY THAT THE PHYSICIAN CERTIFIES 582
IN WRITING, IN THE PHYSICIAN'S OPINION, IS LIKELY TO BE MORE 583
BENEFICIAL TO THE ENROLLEE THAN STANDARD THERAPIES, OR THE 584
ENROLLEE HAS REQUESTED A THERAPY THAT HAS BEEN FOUND, IN A
PREPONDERANCE OF PEER-REVIEWED PUBLISHED STUDIES, TO BE 585
ASSOCIATED WITH EFFECTIVE CLINICAL OUTCOMES FOR THE SAME 586
CONDITION.
(4) THE ENROLLEE HAS BEEN DENIED COVERAGE BY THE PLAN FOR 588
A DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY RECOMMENDED OR 589
REQUESTED PURSUANT TO DIVISION (A)(3) OF THIS SECTION. 590
(5) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, 592
RECOMMENDED PURSUANT TO DIVISION (A)(3) OF THIS SECTION, WOULD BE 593
A COVERED SERVICE EXCEPT FOR THE PLAN'S DETERMINATION THAT THE 594
DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY IS EXPERIMENTAL OR 595
INVESTIGATIONAL.
(B) THE EXTERNAL, INDEPENDENT REVIEW PROCESS ESTABLISHED 597
BY A HEALTH CARE PLAN SHALL MEET ALL OF THE FOLLOWING CRITERIA: 598
(1) THE PLAN OFFERS ALL ENROLLEES WHO MEET THE CRITERIA 600
SET FORTH IN DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE 601
THE REQUESTED THERAPY REVIEWED UNDER THE EXTERNAL, INDEPENDENT 602
REVIEW PROCESS, AND NOTIFIES EACH ELIGIBLE ENROLLEE OF THAT 603
OPPORTUNITY WITHIN FIVE BUSINESS DAYS AFTER THE PLAN DECIDED TO 604
DENY COVERAGE.
(2) THE PLAN CONTRACTS WITH ONE OR MORE IMPARTIAL, 606
INDEPENDENT ENTITIES ACCREDITED PURSUANT TO SECTION 1753.40 OF 607
THE REVISED CODE, THAT ARRANGE FOR REVIEW OF THE COVERAGE 608
DECISION BY SELECTING A PANEL OF AT LEAST TWO PHYSICIANS OR OTHER
PROVIDERS WHO ARE EXPERTS IN THE TREATMENT OF THE ENROLLEE'S 609
15
MEDICAL CONDITION AND KNOWLEDGEABLE ABOUT THE RECOMMENDED 610
THERAPY.
(3) NEITHER THE PLAN NOR THE ENROLLEE CHOOSES, OR CONTROLS 612
THE CHOICE OF, THE PHYSICIAN EXPERTS. 613
(4) NEITHER THE PHYSICIAN EXPERTS NOR THE ENTITY ARRANGING 615
FOR THE EXPERTS' OPINIONS HAVE ANY PROFESSIONAL, FAMILIAL, OR 616
FINANCIAL AFFILIATION WITH THE PLAN, EXCEPT THAT EXPERTS 617
AFFILIATED WITH ACADEMIC MEDICAL CENTERS WHO PROVIDE SERVICES TO 618
PLAN ENROLLEES MAY SERVE AS EXPERTS ON THE REVIEW PANEL. THE 619
REQUIREMENT OF DIVISION (B)(4) OF THIS SECTION DOES NOT PRECLUDE 620
A PLAN FROM PAYING FOR THE EXPERTS' OPINIONS, AS SPECIFIED IN
DIVISION (B)(5) OF THIS SECTION. THE EXPERTS SHALL HAVE NO 621
PATIENT-PHYSICIAN RELATIONSHIP OR OTHER AFFILIATION WITH THE 622
ENROLLEE WHOSE TREATMENT IS UNDER REVIEW OR WITH THE PROVIDER 623
PROPOSING THE THERAPY.
(5) ENROLLEES ARE NOT REQUIRED TO PAY FOR THE EXTERNAL, 625
INDEPENDENT REVIEW. THE COSTS OF THE REVIEW ARE BORNE BY THE 626
PLAN.
(6) THE PLAN PROVIDES TO THE INDEPENDENT ENTITY ARRANGING 628
FOR THE EXPERTS' OPINIONS AND TO THE ENROLLEE AND THE ENROLLEE'S 629
PHYSICIAN A COPY OF THOSE MEDICAL RECORDS IN THE PLAN'S 630
POSSESSION THAT ARE RELEVANT TO THE PATIENT'S CONDITION FOR WHICH 631
THE PROPOSED THERAPY HAS BEEN RECOMMENDED. THE MEDICAL RECORDS 632
SHALL BE DISCLOSED SOLELY TO THE EXPERT REVIEWERS AND SHALL BE 633
USED SOLELY FOR THE PURPOSE OF THIS SECTION. 634
(7) THE OPINIONS OF THE EXPERTS ON THE PANEL ARE RENDERED 636
WITHIN THIRTY DAYS AFTER THE REQUEST FOR REVIEW. IF THE 637
ENROLLEE'S PHYSICIAN DETERMINES THAT THE PROPOSED THERAPY WOULD 638
BE SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, THE 639
OPINIONS ARE RENDERED WITHIN SEVEN DAYS AFTER THE REQUEST FOR 640
REVIEW.
(8) EACH EXPERT ON THE PANEL PROVIDES THE CONTRACTING 642
ENTITY WITH A PROFESSIONAL OPINION AS TO WHETHER THERE IS 643
SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE PROPOSED THERAPY IS 644
16
LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE THAN STANDARD 645
THERAPIES.
(9) EACH EXPERT'S OPINION IS PRESENTED IN WRITTEN FORM AND 647
INCLUDES THE FOLLOWING INFORMATION: 648
(a) A DESCRIPTION OF THE PATIENT'S CONDITION; 650
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO 652
DETERMINING WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE 653
THAT THE PROPOSED THERAPY IS MORE LIKELY THAN NOT TO BE MORE 654
BENEFICIAL TO THE ENROLLEE THAN STANDARD THERAPIES; 655
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS 657
PUBLISHED IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR 658
THE PUBLISHED OPINIONS OF MEDICAL EXPERTS OR SPECIALTY SOCIETIES; 659
(d) A DESCRIPTION OF THE ENROLLEE'S SUITABILITY TO RECEIVE 661
THE PROPOSED THERAPY ACCORDING TO A TREATMENT PROTOCOL IN A 662
CLINICAL TRIAL, IF APPLICABLE. 663
(10) THE CONTRACTING ENTITY PROVIDES THE PLAN WITH THE 665
OPINIONS OF THE EXPERTS. THE PLAN SHALL MAKE THE EXPERTS' 666
OPINIONS AVAILABLE TO THE ENROLLEE AND THE ENROLLEE'S PHYSICIAN, 667
UPON REQUEST.
(11) THE DECISION OF THE MAJORITY OF THE EXPERTS ON THE 669
PANEL, RENDERED PURSUANT TO DIVISION (B)(8) OF THIS SECTION, IS 670
BINDING ON THE PLAN. IF THE OPINIONS OF THE EXPERTS ON THE PANEL 671
ARE EVENLY DIVIDED AS TO WHETHER THE THERAPY SHOULD BE COVERED, 672
THEN THE PLAN'S FINAL DECISION SHALL BE IN FAVOR OF COVERAGE. IF 674
LESS THAN A MAJORITY OF THE EXPERTS ON THE PANEL RECOMMEND
COVERAGE OF THE THERAPY, THE PLAN MAY, IN ITS DISCRETION, COVER 675
THE THERAPY. HOWEVER, ANY COVERAGE PROVIDED PURSUANT TO DIVISION 676
(B)(11) OF THIS SECTION IS SUBJECT TO THE TERMS AND CONDITIONS OF 677
THE ENROLLEE'S CONTRACT WITH THE PLAN. 678
(12) THE PLAN HAS WRITTEN POLICIES DESCRIBING THE 680
EXTERNAL, INDEPENDENT REVIEW PROCESS. THE PLAN SHALL DISCLOSE 681
THE AVAILABILITY OF THE EXTERNAL, INDEPENDENT REVIEW PROCESS IN 682
THE PLAN'S EVIDENCE OF COVERAGE AND DISCLOSURE FORMS. 683
Sec. 1753.40. THE SUPERINTENDENT OF INSURANCE AND THE 685
17
DEPARTMENT OF HEALTH SHALL CONTRACT OR AFFILIATE WITH ONE OR MORE 686
PRIVATE, NONPROFIT ACCREDITING ENTITIES FOR PURPOSES OF 687
ACCREDITING THE INDEPENDENT REVIEW ENTITIES DESCRIBED IN DIVISION 688
(B)(2) OF SECTION 1753.39 OF THE REVISED CODE.
THE SUPERINTENDENT AND THE DIRECTOR OF HEALTH SHALL JOINTLY 690
DEVELOP ACCREDITATION STANDARDS FOR THE ACCREDITATION OF THE 691
INDEPENDENT REVIEW ENTITIES. THE ACCREDITATION STANDARDS SHALL 692
INCLUDE MEASURES THAT ENSURE THE INDEPENDENCE OF THE REVIEW 693
ENTITY, THE CONFIDENTIALITY OF THE MEDICAL RECORDS, AND THE 694
QUALIFICATION AND INDEPENDENCE OF HEALTH CARE PROFESSIONALS
PROVIDING THE EXPERT OPINIONS REQUESTED OF THEM. THE 695
SUPERINTENDENT AND THE DIRECTOR SHALL DEVELOP THESE STANDARDS AND 696
SECURE AN ARRANGEMENT WITH AN ACCREDITING ENTITY OR ENTITIES 697
BEFORE JANUARY 1, 1998.
Sec. 1753.43. (A) AS USED IN THIS SECTION AND SECTION 700
1753.44 OF THE REVISED CODE: 701
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL 703
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF 704
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT 705
LAYPERSON WITH AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD 706
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO 707
RESULT IN ANY OF THE FOLLOWING: 708
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 711
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 712
IN SERIOUS JEOPARDY;
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 715
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 718
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING: 720
(a) A MEDICAL SCREENING EXAMINATION, AS REQUIRED BY 723
FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE EMERGENCY 724
DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY 725
AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN EMERGENCY 726
MEDICAL CONDITION;
(b) SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT THAT 729
18
ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN EMERGENCY MEDICAL 730
CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND 731
BURN CENTER OF THE HOSPITAL. 732
(3)(a) "STABILIZE" MEANS THE PROVISION OF SUCH MEDICAL 735
TREATMENT AS MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE 736
MEDICAL PROBABILITY, THAT NO MATERIAL DETERIORATION OF AN 737
INDIVIDUAL'S MEDICAL CONDITION IS LIKELY TO RESULT FROM OR OCCUR 738
DURING A TRANSFER TO ANOTHER FACILITY, IF THE MEDICAL CONDITION 739
COULD RESULT IN ANY OF THE FOLLOWING:
(i) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 742
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 743
IN SERIOUS JEOPARDY;
(ii) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 746
(iii) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 749
(b) IN THE CASE OF A WOMAN HAVING CONTRACTIONS, 751
"STABILIZE" MEANS SUCH MEDICAL TREATMENT AS MAY BE NECESSARY TO 752
DELIVER, INCLUDING THE PLACENTA. 753
(4) "STABILIZED" MEANS THAT NO MATERIAL DETERIORATION OF 756
AN INDIVIDUAL'S MEDICAL CONDITION, AS DESCRIBED IN DIVISION 757
(A)(3)(a) OF THIS SECTION, IS LIKELY, WITHIN REASONABLE MEDICAL 758
PROBABILITY, TO RESULT FROM OR OCCUR DURING THE TRANSFER OF THE
INDIVIDUAL FROM A FACILITY OR, IN THE CASE OF A WOMAN HAVING 759
CONTRACTIONS, THAT THE WOMAN HAS DELIVERED, INCLUDING THE 760
PLACENTA. 761
(B) A HEALTH CARE PLAN SHALL PROVIDE COVERAGE FOR THE 764
PROVISION OF EMERGENCY SERVICES TO ENROLLEES WITH EMERGENCY 765
MEDICAL CONDITIONS WITHOUT REGARD TO THE DAY OR TIME THE SERVICES 766
ARE RENDERED OR TO WHETHER THE ENROLLEE, OR AN EMERGENCY 767
PHYSICIAN TREATING THE ENROLLEE, OBTAINED PRIOR AUTHORIZATION FOR 768
THE SERVICES.
(C) A HEALTH CARE PLAN SHALL COVER BOTH OF THE FOLLOWING: 771
(1) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A 773
PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE 774
19
PRESENTS HIMSELF OR HERSELF WITH AN EMERGENCY MEDICAL CONDITION; 775
(2) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A 777
NONPARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT UP TO THE POINT 778
OF STABILIZATION IF THE ENROLLEE PRESENTS HIMSELF OR HERSELF WITH 779
AN EMERGENCY MEDICAL CONDITION AND ONE OF THE FOLLOWING 780
CIRCUMSTANCES APPLIES: 781
(a) DUE TO CIRCUMSTANCES BEYOND THE ENROLLEE'S CONTROL, 784
THE ENROLLEE WAS UNABLE TO UTILIZE A PARTICIPATING HOSPITAL'S
EMERGENCY DEPARTMENT WITHOUT SERIOUS THREAT TO LIFE OR HEALTH. 786
(b) A PRUDENT LAYPERSON WITH AN AVERAGE KNOWLEDGE OF 789
HEALTH AND MEDICINE WOULD HAVE REASONABLY BELIEVED THAT, UNDER 790
THE CIRCUMSTANCES, THE TIME REQUIRED TO TRAVEL TO A PARTICIPATING 791
HOSPITAL'S EMERGENCY DEPARTMENT COULD RESULT IN ONE OR MORE OF 792
THE ADVERSE HEALTH CONSEQUENCES DESCRIBED IN DIVISION (A)(1) OF 793
THIS SECTION.
(c) A PERSON AUTHORIZED BY THE HEALTH CARE PLAN REFERS THE 796
ENROLLEE TO AN EMERGENCY DEPARTMENT AND DOES NOT SPECIFY A 797
PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT.
(D) A HEALTH CARE PLAN THAT PROVIDES COVERAGE FOR 800
EMERGENCY MEDICAL SERVICES SHALL INFORM ENROLLEES OF ALL OF THE 801
FOLLOWING:
(1) THE SCOPE OF COVERAGE FOR EMERGENCY MEDICAL SERVICES; 804
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES, INCLUDING 807
THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE ACCESS 808
SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY SERVICES; 809
(3) ANY COST SHARING PROVISIONS FOR EMERGENCY SERVICES; 812
(4) THE PROCEDURES FOR OBTAINING EMERGENCY AND OTHER 814
MEDICAL SERVICES, SO THAT ENROLLEES ARE FAMILIAR WITH THE 815
LOCATION OF THE EMERGENCY DEPARTMENTS OF PARTICIPATING HOSPITALS 816
AND WITH THE LOCATION AND AVAILABILITY OF OTHER PARTICIPATING 817
FACILITIES OR SETTINGS AT WHICH THEY COULD RECEIVE MEDICAL CARE. 818
Sec. 1753.44. (A) EXCEPT AS PROVIDED IN DIVISION (B) OF 821
THIS SECTION, A HEALTH CARE PLAN IS NOT REQUIRED TO REIMBURSE AN 822
EMERGENCY PHYSICIAN OR THE EMERGENCY DEPARTMENT OF A HOSPITAL FOR 823
20
ANY SERVICES OTHER THAN THOSE MEDICALLY NECESSARY TO STABILIZE AN 824
ENROLLEE, UNTIL THE EMERGENCY DEPARTMENT HAS CONTACTED THE PLAN 825
AND THERE IS AGREEMENT BETWEEN THE PHYSICIAN AND THE PLAN 826
CONCERNING TREATMENT AND SERVICES TO BE PROVIDED BY THE PHYSICIAN 827
AFTER THE ENROLLEE IS STABILIZED. 828
(B) A HEALTH CARE PLAN SHALL REIMBURSE AN EMERGENCY 831
PHYSICIAN AND THE EMERGENCY DEPARTMENT OF A HOSPITAL FOR ANY 832
ITEMS OR SERVICES THAT ARE NOT NECESSARY TO STABILIZE THE PATIENT 833
BUT ARE DETERMINED BY THE PHYSICIAN TO BE MEDICALLY NECESSARY, IF 834
ANY OF THE FOLLOWING OCCURS:
(1) AFTER A DOCUMENTED GOOD FAITH EFFORT, THE EMERGENCY 837
DEPARTMENT IS UNABLE TO REACH THE PLAN WITHIN THIRTY MINUTES 838
AFTER THE INITIAL EXAMINATION OF THE ENROLLEE OR, IF THE ENROLLEE 839
NEEDS TO BE STABILIZED, WITHIN THIRTY MINUTES AFTER
STABILIZATION. 840
(2) THE EMERGENCY DEPARTMENT HAS CONTACTED THE PLAN AS 842
REQUIRED IN DIVISION (B)(1) OF THIS SECTION, AND HAS NOT RECEIVED 844
A DENIAL FROM THE PLAN WITHIN THIRTY MINUTES AFTER THE INITIAL 845
CONTACT, UNLESS THE PLAN CAN DOCUMENT THAT IT MADE AN 846
UNSUCCESSFUL GOOD FAITH EFFORT TO REACH THE EMERGENCY DEPARTMENT 847
WITHIN THIRTY MINUTES AFTER RECEIVING THE REQUEST FOR 848
AUTHORIZATION.
(3) THE EMERGENCY DEPARTMENT SUCCESSFULLY CONTACTED THE 851
PLAN AND RECEIVED A DENIAL FROM A PERSON OTHER THAN A
PARTICIPATING PHYSICIAN AND, WITHIN THIRTY MINUTES AFTER THAT 852
DENIAL IS COMMUNICATED TO THE EMERGENCY DEPARTMENT, EITHER OF THE 854
FOLLOWING OCCURS:
(a) A PARTICIPATING PHYSICIAN AUTHORIZED BY THE PLAN TO 857
REVIEW DENIALS REVERSES THE DENIAL.
(b) A PARTICIPATING PHYSICIAN AUTHORIZED BY THE PLAN TO 860
REVIEW DENIALS DOES NOT COMMUNICATE A DETERMINATION AFFIRMING THE 861
DENIAL, UNLESS THE TREATING PHYSICIAN WAIVES THE REQUIREMENT FOR 862
SUCH DETERMINATION.
(C) A HEALTH PLAN SHALL IMMEDIATELY ARRANGE FOR AN 865
21
ALTERNATIVE PLAN OF TREATMENT FOR AN ENROLLEE IF A 866
NONPARTICIPATING EMERGENCY PHYSICIAN AND THE PLAN CANNOT REACH AN 867
AGREEMENT ON SERVICES NECESSARY BEYOND THOSE IMMEDIATELY NEEDED 868
TO STABILIZE THE ENROLLEE. THE ALTERNATIVE PLAN OF TREATMENT 869
SHALL REQUIRE THAT A PARTICIPATING PHYSICIAN WITH PRIVILEGES AT 870
THE HOSPITAL ARRIVE PROMPTLY AT THE HOSPITAL'S EMERGENCY 871
DEPARTMENT AND ASSUME RESPONSIBILITY FOR THE ENROLLEE'S TREATMENT 872
OR, WITH THE AGREEMENT OF THE TREATING PHYSICIAN OR ANY OTHER 873
HEALTH PROFESSIONAL IN THE EMERGENCY DEPARTMENT, THAT ONE OF THE 874
FOLLOWING OCCURS:
(1) AN ARRANGEMENT IS MADE FOR TRANSFER OF THE ENROLLEE TO 877
ANOTHER FACILITY USING MEDICAL RESOURCES CONSISTENT WITH THE
ENROLLEE'S CONDITION; 878
(2) AN APPOINTMENT IS MADE WITH A PARTICIPATING PHYSICIAN 881
OR OTHER HEALTH CARE PROFESSIONAL FOR TREATMENT NEEDED BY THE 882
ENROLLEE;
(3) ANOTHER ARRANGEMENT IS MADE FOR TREATMENT OF THE 884
ENROLLEE. 885
(D) A HEALTH CARE PLAN THAT ARRANGES FOR, OR OTHERWISE 888
COVERS, URGENT CARE SERVICES AND COMPREHENSIVE PRIMARY CARE, MAY 889
IMPOSE DIFFERENT COST-SHARING ON THE ENROLLEE FOR THE FOLLOWING: 890
(1) USE OF AN EMERGENCY DEPARTMENT AS OPPOSED TO ANOTHER 893
SETTING;
(2) USE OF A NONPARTICIPATING HOSPITAL'S EMERGENCY 895
DEPARTMENT AS OPPOSED TO A PARTICIPATING HOSPITAL'S EMERGENCY 896
DEPARTMENT UNLESS, DUE TO CIRCUMSTANCES BEYOND THE ENROLLEE'S 897
CONTROL, THE ENROLLEE WAS UNABLE TO UTILIZE A PARTICIPATING 898
HOSPITAL'S EMERGENCY DEPARTMENT WITHOUT SERIOUS THREAT TO LIFE OR 899
HEALTH, OR A PRUDENT LAYPERSON WITH AN AVERAGE KNOWLEDGE OF 900
HEALTH AND MEDICINE WOULD HAVE REASONABLY BELIEVED THAT, UNDER 901
THE CIRCUMSTANCES, THE TIME REQUIRED TO TRAVEL TO A PARTICIPATING 902
HOSPITAL'S EMERGENCY DEPARTMENT COULD RESULT IN ONE OR MORE OF 903
THE ADVERSE HEALTH CONSEQUENCES DESCRIBED IN DIVISION (A)(1) OF 904
SECTION 1753.43 OF THE REVISED CODE. 905
22
Sec. 1753.46. EACH HEALTH CARE PLAN SHALL IMPLEMENT A 907
COMPREHENSIVE QUALITY ASSURANCE PROGRAM THAT DOES ALL OF THE 908
FOLLOWING:
(A) IDENTIFIES A CORPORATE BOARD OR COMMITTEE OR 910
DESIGNATES AN EXECUTIVE STAFF PERSON RESPONSIBLE FOR PROGRAM 911
IMPLEMENTATION AND COMPLIANCE;
(B) ASSURES THE QUALITY OF PROVIDERS AND FACILITIES WITHIN 913
THE PLAN THROUGH CREDENTIALING, RECREDENTIALING, AND MONITORING 914
PROCEDURES;
(C) REQUIRES ONGOING MONITORING OF QUALITY ASSURANCE 916
PROGRAMS, INCLUDING ITS QUALITY ASSESSMENT PROGRAM AND QUALITY 917
IMPROVEMENT PROGRAM AS PROVIDED IN SECTION 1753.47 OF THE REVISED 918
CODE.
(D) ASSURES A PROCESS FOR COMPLIANCE BY ANY ENTITY OR 920
ENTITIES WITH WHICH THE PLAN CONTRACTS FOR SERVICES; 921
(E) INCLUDES A PROCESS TO TAKE REMEDIAL ACTION TO CORRECT 923
QUALITY PROBLEMS. 924
Sec. 1753.47. TO IMPLEMENT ITS QUALITY ASSURANCE PROGRAM, 926
A HEALTH CARE PLAN SHALL DO BOTH OF THE FOLLOWING: 927
(A) DEVELOP AND MAINTAIN THE INFRASTRUCTURE AND DISCLOSURE 930
SYSTEMS NECESSARY TO MEASURE AND REPORT, ON A REGULAR BASIS, THE 931
QUALITY OF HEALTH CARE SERVICES PROVIDED TO COVERED PERSONS, 932
APPROPRIATE TO THE TYPE OF PLAN, BASED ON SYSTEMATIC COLLECTION, 933
ANALYSIS, AND REPORTING OF RELEVANT DATA. THE PLAN SHALL ASSURE 934
THAT PARTICIPATING PHYSICIANS HAVE THE OPPORTUNITY TO PARTICIPATE 935
IN DEVELOPING, IMPLEMENTING, AND EVALUATING THE QUALITY 936
IMPROVEMENT SYSTEM AND ALL OTHER PROGRAMS IMPLEMENTED BY THE PLAN 937
RELATED TO THE UTILIZATION OF HEALTH CARE SERVICES. 938
PARTICIPATING PHYSICIANS MUST BE INCLUDED IN THE DATA 939
ASSESSMENTS, STATISTICAL ANALYSES, AND OUTCOME INTERPRETATIONS 940
BEING DERIVED FROM PROGRAMS MONITORING THE UTILIZATION OF HEALTH 941
CARE SERVICES.
(B) DEVELOP AND MAINTAIN AN ORGANIZATIONAL PROGRAM FOR 944
DESIGNING, MEASURING, ASSESSING, AND IMPROVING THE PROCESSES AND 945
23
OUTCOMES OF HEALTH CARE. EACH PLAN SHALL FILE A WRITTEN 946
DESCRIPTION OF ITS QUALITY ASSESSMENT PROGRAM AND QUALITY 947
IMPROVEMENT PROGRAM WITH THE DEPARTMENT OF INSURANCE, AND INCLUDE 948
A SIGNED CERTIFICATION THAT THE FILING MEETS THE REQUIREMENTS OF 949
THIS SECTION.
(1) THE PROGRAMS SHALL PROVIDE COVERED PERSONS WITH THE 951
OPPORTUNITY TO COMMENT ON THE QUALITY IMPROVEMENT PROCESS; 952
ESTABLISH AN INTERNAL SYSTEM CAPABLE OF IDENTIFYING OPPORTUNITIES 954
TO IMPROVE CARE, WHICH SYSTEM IS STRUCTURED TO IDENTIFY PRACTICES 955
THAT RESULT IN IMPROVED HEALTH CARE OUTCOMES, TO IDENTIFY 956
PROBLEMATIC UTILIZATION PATTERNS, AND TO IDENTIFY THOSE PROVIDERS 957
THAT MAY BE RESPONSIBLE FOR EITHER EXEMPLARY OR PROBLEMATIC 958
PATTERNS; AND USE THE FINDINGS GENERATED BY THE SYSTEM TO WORK, 959
ON A CONTINUING BASIS, WITH PARTICIPATING PROVIDERS AND OTHER 960
STAFF TO IMPROVE THE HEALTH CARE DELIVERED TO COVERED PERSONS. 961
(2) A HEATH CARE PLAN'S QUALITY IMPROVEMENT PROGRAM SHALL 963
INCLUDE A WRITTEN STATEMENT OF OBJECTIVES, LINES OF AUTHORITY AND 965
ACCOUNTABILITY, EVALUATION TOOLS, AND PERFORMANCE IMPROVEMENT 966
ACTIVITIES; REQUIRE AN ANNUAL EFFECTIVENESS REVIEW OF THE 967
PROGRAM; AND PROVIDE A WRITTEN QUALITY IMPROVEMENT PLAN THAT 968
DESCRIBES HOW THE HEALTH CARE PLAN INTENDS TO DO ALL OF THE
FOLLOWING: 969
(a) ANALYZE BOTH PROCESSES AND OUTCOMES OF CARE, INCLUDING 971
FOCUSED REVIEW OF INDIVIDUAL CASES AS APPROPRIATE, TO DISCERN THE 972
CAUSES OF VARIATION;
(b) IDENTIFY THE TARGETED DIAGNOSES AND TREATMENTS TO BE 974
REVIEWED BY THE QUALITY IMPROVEMENT PROGRAM EACH YEAR, BASED ON 975
CONSIDERATION OF PRACTICES AND DIAGNOSES THAT AFFECT A 976
SUBSTANTIAL NUMBER OF THE HEALTH CARE PLAN'S COVERED PERSONS, OR 977
THAT COULD PLACE COVERED PERSONS AT SERIOUS RISK;
(c) USE A RANGE OF APPROPRIATE METHODS TO ANALYZE QUALITY, 979
INCLUDING COLLECTION AND ANALYSIS OF INFORMATION ON 980
OVER-UTILIZATION AND UNDER-UTILIZATION OF SERVICES; EVALUATION OF 981
COURSES OF TREATMENT AND OUTCOMES BASED ON CURRENT MEDICAL 982
24
RESEARCH, KNOWLEDGE, STANDARDS, AND PRACTICE GUIDELINES; AND 983
COLLECTION AND ANALYSIS OF INFORMATION SPECIFIC TO COVERED
PERSONS OR PROVIDERS; 984
(d) COMPARE PROGRAM FINDINGS WITH PAST PERFORMANCE, 986
INTERNAL GOALS, AND EXTERNAL STANDARDS; 987
(e) MEASURE THE PERFORMANCE OF PARTICIPATING PROVIDERS AND 989
CONDUCT PEER REVIEW ACTIVITIES; 990
(f) UTILIZE TREATMENT PROTOCOLS AND PRACTICE PARAMETERS 992
DEVELOPED WITH APPROPRIATE CLINICAL INPUT; 993
(g) IMPLEMENT IMPROVEMENT STRATEGIES RELATED TO PROGRAM 995
FINDINGS;
(h) EVALUATE PERIODICALLY, BUT NOT LESS THAN ANNUALLY, THE 997
EFFECTIVENESS OF THE IMPROVEMENT STRATEGIES. 998
Sec. 1753.48. (A) THE QUALITY ASSURANCE PROGRAM OF EACH 1,001
HEALTH CARE PLAN SHALL BE SUBJECT TO PERIODIC EXTERNAL 1,002
VERIFICATION, AS FOLLOWS: 1,003
(1) A PANEL OF QUALIFIED HEALTH PROFESSIONALS EXPERIENCED 1,005
IN EVALUATING THE DELIVERY OF HEALTH CARE AND FAMILIAR WITH THE 1,006
OPERATION AND PARAMETERS OF THE TYPE OF PLAN UNDER REVIEW SHALL 1,007
PERIODICALLY CONDUCT AN ONSITE MEDICAL SURVEY OF THE HEALTH 1,008
DELIVERY SYSTEM OF THE PLAN. THE SURVEY SHALL INCLUDE A REVIEW 1,009
OF THE PROCEDURES FOR REGULATING UTILIZATION, PEER REVIEW 1,010
MECHANISMS, INTERNAL PROCEDURES OF ASSURING QUALITY OF CARE, AND 1,011
THE OVERALL PERFORMANCE OF THE PLAN IN PROVIDING HEALTH CARE 1,012
BENEFITS AND MEETING THE HEALTH CARE NEEDS OF THE ENROLLEES. 1,013
(2) SURVEYS PERFORMED PURSUANT TO DIVISION (A)(1) OF THIS 1,016
SECTION SHALL BE CONDUCTED AT THE REQUEST OF THE SUPERINTENDENT 1,017
OF INSURANCE AS OFTEN AS THE SUPERINTENDENT CONSIDERS NECESSARY 1,018
TO ASSURE THE PROTECTION OF SUBSCRIBERS AND ENROLLEES, BUT NOT 1,019
LESS FREQUENTLY THAN ONCE EVERY THREE YEARS. NOTHING IN THIS 1,020
SECTION SHALL BE CONSTRUED TO REQUIRE THE PANEL CONDUCTING THE 1,021
SURVEY TO VISIT EVERY CLINIC, HOSPITAL OFFICE, OR OTHER FACILITY 1,022
OF THE HEALTH CARE PLAN. 1,023
(3) REVIEWS CONDUCTED BY PROFESSIONAL STANDARDS REVIEW 1,025
25
ORGANIZATIONS AND SURVEYS AND AUDITS CONDUCTED BY OTHER 1,026
GOVERNMENTAL ENTITIES SHALL BE DEEMED TO MEET THE REQUIREMENTS OF 1,028
DIVISION (A) OF THIS SECTION. 1,029
(B) THIS SECTION DOES NOT REQUIRE ACCREDITATION OF HEALTH 1,032
CARE PLANS BY INDEPENDENT, PRIVATE ORGANIZATIONS. TO THE EXTENT 1,033
THAT ACCREDITATION OF A HEALTH CARE PLAN BY A PRIVATE 1,034
ORGANIZATION MEETS FEDERAL QUALITY REVIEW REQUIREMENTS, THE 1,035
CORRESPONDING REQUIREMENTS OF DIVISION (A) OF THIS SECTION ARE 1,036
DEEMED TO HAVE BEEN MET. 1,037
Sec. 1753.49. A HEALTH CARE PLAN THAT IS ACCREDITED BY THE 1,039
NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION ON 1,040
ACCREDITATION OF HEALTHCARE ORGANIZATIONS, THE UTILIZATION REVIEW 1,041
ACCREDITATION COMMISSION, OR ANY OTHER QUALIFIED ORGANIZATION 1,042
DESIGNATED IN RULES ADOPTED BY THE SUPERINTENDENT OF INSURANCE IN 1,043
ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, IS DEEMED TO BE 1,044
IN COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1753.46 TO
1753.48 OF THE REVISED CODE. 1,045
Sec. 1753.51. (A) EACH HEALTH CARE PLAN SHALL ESTABLISH A 1,048
POLICY REGARDING THE AVAILABILITY AND CONFIDENTIALITY OF THOSE
HEALTH RECORDS MAINTAINED BY PROVIDERS AND HEALTH CARE FACILITIES 1,049
TO MONITOR AND EVALUATE THE QUALITY OF CARE, TO CONDUCT 1,050
EVALUATIONS AND AUDITS, AND TO DETERMINE ON A CONCURRENT OR 1,051
RETROSPECTIVE BASIS THE NECESSITY OF AND APPROPRIATENESS OF 1,052
HEALTH CARE SERVICES PROVIDED TO ENROLLEES. THE POLICY SHALL 1,053
REQUIRE THE PROVIDER OR HEALTH CARE FACILITY TO MAKE THESE HEALTH
RECORDS AVAILABLE TO APPROPRIATE STATE AND FEDERAL AUTHORITIES 1,054
INVOLVED IN ASSESSING THE QUALITY OF CARE OR IN INVESTIGATING THE 1,055
GRIEVANCES OR COMPLAINTS OF ENROLLEES. 1,056
(B) IF AN ENROLLEE SIGNS A MEDICAL INFORMATION RELEASE FOR 1,058
A HEALTH CARE PLAN, THE RELEASE SHALL CLEARLY EXPLAIN WHAT 1,059
INFORMATION MAY BE DISCLOSED UNDER THE TERMS OF THE RELEASE. IF 1,060
A HEALTH CARE PLAN UTILIZES THIS RELEASE TO REQUEST MEDICAL 1,061
INFORMATION FROM A HEALTH CARE PROVIDER, THE PLAN SHALL PROVIDE A 1,062
COPY OF THE ENROLLEE'S RELEASE TO THE HEALTH CARE PROVIDER, UPON 1,063
26
REQUEST.
(C) EACH HEALTH CARE PLAN, PROVIDER, AND FACILITY SHALL 1,065
COMPLY WITH ALL APPLICABLE STATE AND FEDERAL LAWS RELATED TO THE 1,066
CONFIDENTIALITY OF MEDICAL OR HEALTH RECORDS. 1,067
Sec. 1753.66. AS USED IN SECTIONS 1753.66 TO 1753.75 OF 1,069
THE REVISED CODE, UNLESS OTHERWISE SPECIFICALLY PROVIDED: 1,070
(A) "ADVERSE DETERMINATION" MEANS A DETERMINATION BY A 1,072
HEALTH CARRIER OR ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION 1,073
THAT AN ADMISSION, AVAILABILITY OF CARE, CONTINUED STAY, OR OTHER 1,074
HEALTH CARE SERVICE HAS BEEN REVIEWED AND, BASED UPON THE 1,075
INFORMATION PROVIDED, DOES NOT MEET THE HEALTH CARRIER'S 1,076
REQUIREMENTS FOR MEDICAL NECESSITY, APPROPRIATENESS, HEALTH CARE
SETTING, LEVEL OF CARE, OR EFFECTIVENESS, AND THAT THE REQUESTED 1,077
SERVICE IS THEREFORE DENIED, REDUCED, OR TERMINATED. 1,078
(B) "AMBULATORY REVIEW" MEANS UTILIZATION REVIEW OF HEALTH 1,080
CARE SERVICES PERFORMED OR PROVIDED IN AN OUTPATIENT SETTING. 1,081
(C) "APPEALS PROCEDURE" MEANS A FORMAL PROCESS IN WHICH A 1,083
COVERED PERSON, A REPRESENTATIVE OF A COVERED PERSON, AN 1,084
ATTENDING PHYSICIAN, A FACILITY, OR A HEALTH CARE PROVIDER CAN 1,085
CONTEST AN ADVERSE DETERMINATION RENDERED BY THE HEALTH CARRIER 1,086
OR ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION. 1,087
(D) "CASE MANAGEMENT" MEANS A COORDINATED SET OF 1,089
ACTIVITIES CONDUCTED FOR INDIVIDUAL PATIENT MANAGEMENT OF 1,090
SERIOUS, COMPLICATED, PROTRACTED, OR OTHER SPECIFIED HEALTH 1,091
CONDITIONS.
(E) "CERTIFICATION" MEANS A DETERMINATION BY A HEALTH 1,093
CARRIER OR ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION THAT AN 1,094
ADMISSION, AVAILABILITY OF CARE, CONTINUED STAY, OR OTHER HEALTH 1,095
CARE SERVICE HAS BEEN REVIEWED AND, BASED ON THE INFORMATION 1,096
PROVIDED, SATISFIES THE HEALTH CARRIER'S REQUIREMENTS FOR MEDICAL 1,097
NECESSITY, APPROPRIATENESS, HEALTH CARE SETTING, LEVEL OF CARE,
AND EFFECTIVENESS. 1,098
(F) "CLINICAL PEER" MEANS A PHYSICIAN IN THE SAME OR 1,100
SIMILAR SPECIALTY AS TYPICALLY MANAGES THE MEDICAL CONDITION, 1,101
27
PROCEDURE, OR TREATMENT UNDER REVIEW. 1,102
(G) "CLINICAL REVIEW CRITERIA" MEANS THE WRITTEN SCREENING 1,104
PROCEDURES, DECISION ABSTRACTS, CLINICAL PROTOCOLS, AND PRACTICE 1,105
GUIDELINES USED BY THE HEALTH CARRIER TO DETERMINE THE NECESSITY 1,106
AND APPROPRIATENESS OF HEALTH CARE SERVICES. 1,107
(H) "CONCURRENT REVIEW" MEANS UTILIZATION REVIEW CONDUCTED 1,109
DURING A PATIENT'S HOSPITAL STAY OR COURSE OF TREATMENT. 1,110
(I) "COVERED PERSON" MEANS THE POLICYHOLDER, SUBSCRIBER, 1,112
ENROLLEE, OR OTHER INDIVIDUAL PARTICIPATING IN A HEALTH BENEFIT 1,113
PLAN.
(J) "DISCHARGE PLANNING" MEANS THE FORMAL PROCESS FOR 1,115
DETERMINING, PRIOR TO DISCHARGE FROM A FACILITY, THE COORDINATION 1,116
AND MANAGEMENT OF THE CARE THAT A PATIENT RECEIVES FOLLOWING 1,117
DISCHARGE FROM A FACILITY. 1,118
(K) "FACILITY" MEANS AN INSTITUTION PROVIDING HEALTH CARE 1,120
SERVICES OR A HEALTH CARE SETTING, INCLUDING BUT NOT LIMITED TO 1,121
HOSPITALS AND OTHER LICENSED INPATIENT CENTERS, AMBULATORY 1,122
SURGICAL OR TREATMENT CENTERS, SKILLED NURSING CENTERS, 1,123
RESIDENTIAL TREATMENT CENTERS, DIAGNOSTIC, LABORATORY AND IMAGING 1,124
CENTERS, AND REHABILITATION AND OTHER THERAPEUTIC HEALTH 1,125
SETTINGS.
(L) "HEALTH BENEFIT PLAN" MEANS A POLICY, CONTRACT, 1,127
CERTIFICATE, OR AGREEMENT ENTERED INTO, OFFERED, OR ISSUED BY A 1,128
HEALTH CARRIER TO PROVIDE, DELIVER, ARRANGE FOR, PAY FOR, OR 1,129
REIMBURSE ANY OF THE COSTS OF HEALTH CARE SERVICES. 1,130
(M) "HEALTH CARE PROFESSIONAL" MEANS A PHYSICIAN OR OTHER 1,132
HEALTH CARE PRACTITIONER WHO HAS A CURRENT NONRESTRICTED LICENSE, 1,133
IS ACCREDITED, OR IS CERTIFIED TO PERFORM SPECIFIED HEALTH 1,134
SERVICES IN ACCORDANCE WITH THE LAW OF THE STATE IN WHICH THE 1,135
PROFESSIONAL PRACTICES.
(N) "HEALTH CARE PROVIDER" OR "PROVIDER" MEANS A HEALTH 1,137
CARE PROFESSIONAL OR A FACILITY. 1,138
(O) "HEALTH CARE SERVICES" MEANS SERVICES FOR THE 1,140
DIAGNOSIS, PREVENTION, TREATMENT, CURE, OR RELIEF OF A HEALTH 1,141
28
CONDITION, ILLNESS, INJURY, OR DISEASE. 1,142
(P) "HEALTH CARRIER" MEANS AN ENTITY SUBJECT TO REGULATION 1,144
UNDER TITLE XVII OR XXXIX OF THE REVISED CODE THAT CONTRACTS OR 1,145
OFFERS TO CONTRACT TO PROVIDE, DELIVER, ARRANGE FOR, PAY FOR, OR 1,146
REIMBURSE ANY OF THE COSTS OF HEALTH CARE SERVICES, INCLUDING A 1,147
SICKNESS AND ACCIDENT INSURANCE COMPANY, A HEALTH MAINTENANCE 1,148
ORGANIZATION, OR ANY OTHER ENTITY PROVIDING A PLAN OF HEALTH 1,149
INSURANCE, HEALTH BENEFITS, OR HEALTH SERVICES.
(Q) "PARTICIPATING PROVIDER" MEANS A PROVIDER THAT, UNDER 1,151
A CONTRACT WITH THE HEALTH CARRIER OR WITH ITS CONTRACTOR OR 1,152
SUBCONTRACTOR, HAS AGREED TO PROVIDE HEALTH CARE SERVICES TO 1,153
COVERED PERSONS WITH AN EXPECTATION OF RECEIVING PAYMENT, OTHER 1,154
THAN COINSURANCE, COPAYMENTS, OR DEDUCTIBLES, DIRECTLY OR 1,155
INDIRECTLY FROM THE HEALTH CARRIER.
(R) "PERSON" MEANS AN INDIVIDUAL, A CORPORATION, A 1,157
PARTNERSHIP, AN ASSOCIATION, A JOINT VENTURE, A JOINT STOCK 1,158
COMPANY, A TRUST, AN UNINCORPORATED ORGANIZATION, OR OTHER 1,159
SIMILAR ENTITY, OR ANY COMBINATION THEREOF. 1,160
(S) "PROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW THAT IS 1,162
CONDUCTED PRIOR TO AN ADMISSION OR A COURSE OF TREATMENT. 1,163
(T) "RETROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW OF 1,165
MEDICAL NECESSITY THAT IS CONDUCTED AFTER SERVICES HAVE BEEN 1,166
PROVIDED TO A PATIENT. "RETROSPECTIVE REVIEW" DOES NOT INCLUDE 1,167
THE REVIEW OF A CLAIM THAT IS LIMITED TO AN EVALUATION OF 1,168
REIMBURSEMENT LEVELS, VERACITY OF DOCUMENTATION, ACCURACY OF 1,169
CODING, OR ADJUDICATION OF PAYMENT.
(U) "SECOND OPINION" MEANS AN OPPORTUNITY OR REQUIREMENT 1,171
TO OBTAIN A CLINICAL EVALUATION BY A PROVIDER OTHER THAN THE ONE 1,172
ORIGINALLY MAKING A RECOMMENDATION FOR PROPOSED HEALTH CARE 1,173
SERVICES TO ASSESS THE CLINICAL NECESSITY AND APPROPRIATENESS OF 1,174
THE INITIAL PROPOSED HEALTH CARE SERVICES. 1,175
(V) "UTILIZATION REVIEW" MEANS A PROCESS USED TO MONITOR 1,177
THE USE OF, OR EVALUATE THE CLINICAL NECESSITY, APPROPRIATENESS, 1,178
EFFICACY, OR EFFICIENCY OF, HEALTH CARE SERVICES, PROCEDURES, OR 1,179
29
SETTINGS. AREAS OF REVIEW MAY INCLUDE AMBULATORY REVIEW, 1,180
PROSPECTIVE REVIEW, SECOND OPINION, CERTIFICATION, CONCURRENT 1,181
REVIEW, CASE MANAGEMENT, DISCHARGE PLANNING, OR RETROSPECTIVE 1,182
REVIEW.
(W) "UTILIZATION REVIEW ORGANIZATION" MEANS AN ENTITY THAT 1,184
CONDUCTS UTILIZATION REVIEW, OTHER THAN A HEALTH CARE PROVIDER 1,185
PERFORMING A REVIEW FOR ITS OWN HEALTH BENEFIT PLANS. 1,186
Sec. 1753.67. (A) SECTIONS 1753.66 TO 1753.75 OF THE 1,190
REVISED CODE APPLY TO ANY HEALTH CARRIER THAT PROVIDES OR 1,192
PERFORMS UTILIZATION REVIEW SERVICES AND TO ANY DESIGNEE OF THE 1,193
HEALTH CARRIER, OR TO ANY UTILIZATION REVIEW ORGANIZATION THAT 1,194
PERFORMS UTILIZATION REVIEW FUNCTIONS ON BEHALF OF THE HEALTH 1,195
CARRIER.
(B)(1) EACH HEALTH CARRIER SHALL BE RESPONSIBLE FOR 1,198
MONITORING ALL UTILIZATION REVIEW ACTIVITIES CARRIED OUT BY, OR 1,199
ON BEHALF OF, THE HEALTH CARRIER AND FOR ENSURING THAT ALL 1,200
REQUIREMENTS OF SECTIONS 1753.66 TO 1753.75 OF THE REVISED CODE, 1,203
AND ANY RULES ADOPTED THEREUNDER, ARE MET. THE HEALTH CARRIER 1,204
SHALL ALSO ENSURE THAT APPROPRIATE PERSONNEL HAVE OPERATIONAL 1,205
RESPONSIBILITY FOR THE CONDUCT OF THE HEALTH CARRIER'S 1,206
UTILIZATION REVIEW PROGRAM. 1,207
(2) IF A HEALTH CARRIER CONTRACTS TO HAVE A UTILIZATION 1,209
REVIEW ORGANIZATION OR OTHER ENTITY PERFORM THE UTILIZATION 1,210
REVIEW FUNCTIONS REQUIRED BY SECTIONS 1753.66 TO 1753.75 OF THE 1,212
REVISED CODE OR ANY RULES ADOPTED THEREUNDER, THE SUPERINTENDENT 1,214
OF INSURANCE SHALL HOLD THE HEALTH CARRIER RESPONSIBLE FOR 1,215
MONITORING THE ACTIVITIES OF THE UTILIZATION REVIEW ORGANIZATION 1,216
OR OTHER ENTITY AND FOR ENSURING THAT THE REQUIREMENTS OF THOSE 1,217
SECTIONS AND RULES ARE MET. 1,218
Sec. 1753.68. A HEALTH CARRIER THAT CONDUCTS UTILIZATION 1,220
REVIEW SHALL PREPARE A WRITTEN UTILIZATION REVIEW PROGRAM THAT 1,221
DESCRIBES ALL REVIEW ACTIVITIES, BOTH DELEGATED AND NONDELEGATED, 1,222
FOR COVERED SERVICES PROVIDED, INCLUDING THE FOLLOWING: 1,223
(A) PROCEDURES TO EVALUATE THE CLINICAL NECESSITY, 1,225
30
APPROPRIATENESS, EFFICACY, OR EFFICIENCY OF HEALTH SERVICES; 1,227
(B) DATA SOURCES AND CLINICAL REVIEW CRITERIA USED IN 1,229
MAKING DECISIONS; 1,230
(C) THE PROCESS FOR CONDUCTING APPEALS OF ADVERSE 1,232
DETERMINATIONS;
(D) MECHANISMS TO ENSURE CONSISTENT APPLICATION OF 1,234
CRITERIA AND COMPATIBLE DECISIONS; 1,235
(E) DATA COLLECTION PROCESSES AND ANALYTICAL METHODS USED 1,237
IN ASSESSING UTILIZATION OF HEALTH CARE SERVICES; 1,239
(F) PROVISIONS FOR ASSURING CONFIDENTIALITY OF CLINICAL 1,241
AND PROPRIETARY INFORMATION; 1,242
(G) THE ORGANIZATIONAL STRUCTURE, SUCH AS UTILIZATION 1,244
REVIEW, QUALITY ASSURANCE, OR OTHER COMMITTEE, THAT PERIODICALLY 1,245
ASSESSES UTILIZATION REVIEW ACTIVITIES AND REPORTS TO THE HEALTH 1,246
CARRIER'S GOVERNING BODY;
(H) THE STAFF POSITION FUNCTIONALLY RESPONSIBLE FOR 1,248
DAY-TO-DAY PROGRAM MANAGEMENT; 1,249
(I) DEFINED METHODS BY WHICH GUIDELINES ARE APPROVED AND 1,251
COMMUNICATED TO PROVIDERS. 1,252
Sec. 1753.69. THE UTILIZATION REVIEW PROGRAM OF A HEALTH 1,254
CARRIER SHALL BE IMPLEMENTED IN ACCORDANCE WITH ALL OF THE 1,255
FOLLOWING: 1,256
(A) THE PROGRAM SHALL USE DOCUMENTED CLINICAL REVIEW 1,259
CRITERIA THAT ARE BASED ON SOUND CLINICAL EVIDENCE AND ARE 1,260
EVALUATED PERIODICALLY TO ASSURE ONGOING EFFICACY. A HEALTH 1,261
CARRIER MAY DEVELOP ITS OWN CLINICAL REVIEW CRITERIA OR MAY 1,262
PURCHASE OR LICENSE SUCH CRITERIA FROM QUALIFIED VENDORS. A 1,263
HEALTH BENEFIT PLAN SHALL MAKE ITS CLINICAL REVIEW RATIONALE 1,264
AVAILABLE UPON REQUEST TO AUTHORIZED GOVERNMENT AGENCIES. 1,265
(B) QUALIFIED HEALTH CARE PROFESSIONALS SHALL ADMINISTER 1,268
THE PROGRAM AND OVERSEE REVIEW DECISIONS. A CLINICAL PEER SHALL 1,269
EVALUATE THE CLINICAL APPROPRIATENESS OF ADVERSE DETERMINATIONS 1,270
THAT ARE THE SUBJECT OF AN APPEAL. 1,271
(C) THE HEALTH CARRIER SHALL ISSUE UTILIZATION REVIEW 1,274
31
DECISIONS IN A TIMELY MANNER PURSUANT TO THE REQUIREMENTS OF 1,275
SECTIONS 1753.70 AND 1753.71 OF THE REVISED CODE AND THE ENROLLEE 1,277
GRIEVANCE REQUIREMENTS. THE CARRIER SHALL OBTAIN INFORMATION 1,278
REQUIRED TO MAKE A UTILIZATION REVIEW DECISION, INCLUDING 1,279
PERTINENT CLINICAL INFORMATION, AND SHALL ESTABLISH A PROCESS TO 1,280
ENSURE THAT UTILIZATION REVIEWERS APPLY CLINICAL REVIEW CRITERIA 1,281
CONSISTENTLY. 1,282
(D) IF THE HEALTH CARRIER DELEGATES ANY UTILIZATION REVIEW 1,285
ACTIVITIES TO A UTILIZATION REVIEW ORGANIZATION, THE CARRIER 1,286
SHALL MAINTAIN ADEQUATE OVERSIGHT, WHICH SHALL INCLUDE ALL OF THE 1,287
FOLLOWING: 1,288
(1) A WRITTEN DESCRIPTION OF THE ORGANIZATION'S ACTIVITIES 1,291
AND RESPONSIBILITIES, INCLUDING REPORTING REQUIREMENTS; 1,292
(2) EVIDENCE OF FORMAL APPROVAL OF THE ORGANIZATION'S 1,294
PROGRAM BY THE HEALTH CARRIER; 1,295
(3) A PROCESS BY WHICH THE HEALTH CARRIER EVALUATES THE 1,297
PERFORMANCE OF THE ORGANIZATION. 1,298
(E) THE HEALTH CARRIER OR ITS DESIGNEE UTILIZATION REVIEW 1,301
ORGANIZATION SHALL PROVIDE COVERED PERSONS AND PARTICIPATING 1,302
PROVIDERS WITH ACCESS TO ITS REVIEW STAFF BY MEANS OF A TOLL-FREE 1,303
TELEPHONE NUMBER OR COLLECT-CALL TELEPHONE LINE. 1,304
(F) WHEN CONDUCTING PROSPECTIVE OR CONCURRENT REVIEW, THE 1,307
HEALTH CARRIER OR ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION 1,308
SHALL COLLECT ONLY THE INFORMATION NECESSARY TO CERTIFY THE 1,309
ADMISSION, PROCEDURE OR TREATMENT, LENGTH OF STAY, FREQUENCY, AND 1,310
DURATION OF SERVICES. 1,311
(G) COMPENSATION TO PERSONS PROVIDING UTILIZATION REVIEW 1,314
SERVICES FOR THE HEALTH CARRIER SHALL NOT CONTAIN INCENTIVES, 1,315
DIRECT OR INDIRECT, FOR THEM TO MAKE INAPPROPRIATE REVIEW 1,316
DECISIONS.
Sec. 1753.70. (A) AS USED IN THIS SECTION: 1,318
(1) "COVERED PERSON" INCLUDES THE REPRESENTATIVE OF A 1,320
COVERED PERSON.
(2) "NECESSARY INFORMATION" INCLUDES THE RESULTS OF ANY 1,322
32
FACE-TO-FACE CLINICAL EVALUATION OR SECOND OPINION THAT MAY BE 1,324
REQUIRED.
(B) A HEALTH CARRIER SHALL MAINTAIN WRITTEN PROCEDURES FOR 1,326
MAKING UTILIZATION REVIEW DECISIONS AND FOR NOTIFYING COVERED 1,327
PERSONS, AND PROVIDERS ACTING ON BEHALF OF COVERED PERSONS, OF 1,328
ITS DECISIONS.
(C) FOR INITIAL DETERMINATIONS, A HEALTH CARRIER SHALL 1,330
MAKE THE DETERMINATION WITHIN TWO BUSINESS DAYS OF OBTAINING ALL 1,331
NECESSARY INFORMATION REGARDING A PROPOSED ADMISSION, PROCEDURE, 1,332
OR SERVICE REQUIRING A REVIEW DETERMINATION. 1,333
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN 1,335
ADMISSION, PROCEDURE, OR SERVICE, THE CARRIER SHALL NOTIFY THE 1,336
PROVIDER RENDERING THE SERVICE BY TELEPHONE WITHIN SEVENTY-TWO 1,337
HOURS OF MAKING THE INITIAL CERTIFICATION, AND SHALL PROVIDE 1,338
WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE NOTIFICATION
TO THE COVERED PERSON AND THE PROVIDER WITHIN TWO BUSINESS DAYS 1,339
OF MAKING THE INITIAL CERTIFICATION. 1,340
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE CARRIER 1,342
SHALL NOTIFY THE PROVIDER RENDERING THE SERVICE BY TELEPHONE 1,343
WITHIN SEVENTY-TWO HOURS OF MAKING THE ADVERSE DETERMINATION, AND 1,344
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE 1,345
NOTIFICATION TO THE COVERED PERSON AND THE PROVIDER WITHIN ONE 1,346
BUSINESS DAY OF MAKING THE ADVERSE DETERMINATION.
(D) FOR CONCURRENT REVIEW DETERMINATIONS, A HEALTH CARRIER 1,348
SHALL MAKE THE DETERMINATION WITHIN ONE BUSINESS DAY OF OBTAINING 1,349
ALL NECESSARY INFORMATION. 1,350
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN EXTENDED 1,352
STAY OR ADDITIONAL SERVICES, THE CARRIER SHALL NOTIFY BY 1,353
TELEPHONE THE PROVIDER RENDERING THE SERVICE WITHIN ONE BUSINESS 1,354
DAY OF MAKING THE CERTIFICATION, AND SHALL PROVIDE WRITTEN OR 1,355
ELECTRONIC CONFIRMATION TO THE COVERED PERSON AND THE PROVIDER 1,356
WITHIN ONE BUSINESS DAY AFTER THE TELEPHONE NOTIFICATION. THE 1,357
WRITTEN NOTIFICATION SHALL INCLUDE THE NUMBER OF EXTENDED DAYS OR 1,358
NEXT REVIEW DATE, THE NEW TOTAL NUMBER OF DAYS OR SERVICES
33
APPROVED, AND THE DATE OF ADMISSION OR INITIATION OF SERVICES. 1,359
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE CARRIER 1,361
SHALL NOTIFY BY TELEPHONE THE PROVIDER RENDERING THE SERVICE 1,362
WITHIN TWENTY-FOUR HOURS OF MAKING THE ADVERSE DETERMINATION, AND 1,363
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION TO THE COVERED 1,364
PERSON AND THE PROVIDER WITHIN ONE BUSINESS DAY OF THE TELEPHONE 1,365
NOTIFICATION. THE SERVICE SHALL BE CONTINUED WITHOUT LIABILITY
TO THE COVERED PERSON UNTIL THE COVERED PERSON HAS BEEN NOTIFIED 1,366
OF THE DETERMINATION. 1,367
(E) FOR RETROSPECTIVE REVIEW DETERMINATIONS, A HEALTH 1,369
CARRIER SHALL MAKE THE DETERMINATION WITHIN THIRTY BUSINESS DAYS 1,371
OF RECEIVING ALL NECESSARY INFORMATION. 1,372
(1) IN THE CASE OF A CERTIFICATION, THE CARRIER MAY NOTIFY 1,374
IN WRITING THE COVERED PERSON AND THE PROVIDER RENDERING THE 1,375
SERVICE.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE CARRIER 1,377
SHALL NOTIFY IN WRITING THE PROVIDER RENDERING THE SERVICE AND 1,378
THE COVERED PERSON WITHIN FIVE BUSINESS DAYS OF MAKING THE 1,379
ADVERSE DETERMINATION.
(F) THE TIME FRAMES SET FORTH IN DIVISIONS (C), (D), AND 1,382
(E) OF THIS SECTION FOR INITIAL DETERMINATIONS AND NOTIFICATIONS 1,383
SHALL PREVAIL UNLESS THE SERIOUSNESS OF THE MEDICAL CONDITION OF
THE COVERED PERSON OTHERWISE REQUIRES A MORE TIMELY RESPONSE FROM 1,384
THE HEALTH BENEFIT PLAN. THE HEALTH BENEFIT PLAN SHALL MAINTAIN 1,385
WRITTEN PROCEDURES FOR MAKING EXPEDITED UTILIZATION REVIEW 1,386
DECISIONS AND FOR NOTIFYING COVERED PERSONS OR PROVIDERS WHEN 1,387
WARRANTED BY THE MEDICAL CONDITION OF THE COVERED PERSON. 1,388
(G) A WRITTEN NOTIFICATION OF AN ADVERSE DETERMINATION 1,390
SHALL INCLUDE THE PRINCIPAL REASON OR REASONS FOR THE 1,391
DETERMINATION, THE INSTRUCTION FOR INITIATING AN APPEAL OR 1,392
RECONSIDERATION OF THE DETERMINATION, AND THE INSTRUCTIONS FOR 1,393
REQUESTING A WRITTEN STATEMENT OF THE CLINICAL RATIONALE USED TO 1,394
MAKE THE DETERMINATION. A HEALTH CARRIER SHALL PROVIDE THE
CLINICAL RATIONALE IN WRITING FOR AN ADVERSE DETERMINATION TO ANY 1,396
34
PARTY WHO RECEIVED NOTICE OF THE ADVERSE DETERMINATION AND WHO 1,397
FOLLOWS THE PROCEDURES FOR A REQUEST. 1,398
(H) A HEALTH CARRIER SHALL HAVE WRITTEN PROCEDURES TO 1,400
ADDRESS THE FAILURE OR INABILITY OF A PROVIDER OR A COVERED 1,401
PERSON TO PROVIDE ALL NECESSARY INFORMATION FOR REVIEW. IF THE 1,402
PROVIDER OR COVERED PERSON WILL NOT RELEASE NECESSARY 1,403
INFORMATION, THE HEALTH CARRIER MAY DENY CERTIFICATION.
Sec. 1753.71. (A) IN A CASE INVOLVING AN INITIAL 1,406
DETERMINATION OR A CONCURRENT REVIEW DETERMINATION, A HEALTH 1,407
CARRIER SHALL GIVE THE PROVIDER RENDERING THE SERVICE AN 1,408
OPPORTUNITY TO REQUEST IN WRITING ON BEHALF OF THE COVERED PERSON 1,409
A RECONSIDERATION OF AN ADVERSE DETERMINATION BY THE REVIEWER 1,410
MAKING THE ADVERSE DETERMINATION. THE RECONSIDERATION SHALL 1,411
OCCUR WITHIN ONE BUSINESS DAY AFTER RECEIPT OF THE WRITTEN 1,412
REQUEST, AND SHALL BE CONDUCTED BETWEEN THE PROVIDER RENDERING 1,413
THE SERVICE AND THE REVIEWER WHO MADE THE ADVERSE DETERMINATION. 1,414
IF THAT REVIEWER CANNOT BE AVAILABLE WITHIN ONE BUSINESS DAY, THE 1,415
REVIEWER MAY DESIGNATE ANOTHER REVIEWER.
(B) IF THE RECONSIDERATION PROCESS DESCRIBED IN DIVISION 1,419
(A) OF THIS SECTION DOES NOT RESOLVE THE DIFFERENCE OF OPINION, 1,420
THE ADVERSE DETERMINATION MAY BE APPEALED BY THE COVERED PERSON 1,421
OR THE PROVIDER ON BEHALF OF THE COVERED PERSON. 1,422
(C) RECONSIDERATION IS NOT A PREREQUISITE TO A STANDARD OR 1,425
EXPEDITED APPEAL OF AN ADVERSE DETERMINATION. 1,426
Sec. 1753.72. A HEALTH BENEFIT PLAN THAT IS ACCREDITED BY 1,428
THE NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION 1,429
ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS, THE UTILIZATION 1,430
REVIEW ACCREDITATION COMMISSION, OR ANY OTHER QUALIFIED 1,431
ORGANIZATION DESIGNATED IN RULES ADOPTED BY THE SUPERINTENDENT OF 1,432
INSURANCE IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, IS
DEEMED TO BE IN COMPLIANCE WITH SECTIONS 1753.66 TO 1753.71 OF 1,433
THE REVISED CODE.
Sec. 1753.73. EACH PROVIDER SHALL COOPERATE WITH THE 1,435
UTILIZATION REVIEW PROGRAM OF A HEALTH CARRIER OR UTILIZATION 1,436
35
REVIEW ORGANIZATION AND SHALL PROVIDE THE CARRIER OR ITS DESIGNEE 1,438
ACCESS TO AN ENROLLEE'S MEDICAL RECORDS DURING REGULAR BUSINESS 1,439
HOURS, OR COPIES OF THOSE RECORDS AT A REASONABLE COST. 1,440
Sec. 1753.75. (A) NO HEALTH CARRIER SHALL FAIL TO COMPLY 1,443
WITH SECTIONS 1753.66 TO 1753.71 OF THE REVISED CODE. 1,444
(B) WHOEVER VIOLATES DIVISION (A) OF THIS SECTION IS 1,447
DEEMED TO HAVE ENGAGED IN AN UNFAIR AND DECEPTIVE ACT OR PRACTICE 1,449
IN THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 TO 3901.26 OF 1,450
THE REVISED CODE.
Sec. 1753.81. NOTHING IN SECTIONS 1753.01 TO 1753.51 OR 1,452
1753.66 TO 1753.75 OF THE REVISED CODE SHALL PREVENT OR OTHERWISE 1,454
AFFECT THE APPLICATION OF TITLE XXXIX OR ANY OTHER PROVISION OF 1,455
TITLE XVII OF THE REVISED CODE TO ANY HEALTH CARE PLAN TO WHICH 1,457
IT WOULD OTHERWISE APPLY.