As Reported by the House Insurance Committee 1
122nd General Assembly 4
Regular Session Sub. 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-PADGETT-PERZ- 10
SALERNO-SAWYER-SCHULER-SCHURING-STAPLETON-TAYLOR-TERWILLEGER- 11
TIBERI-VESPER-WACHTMANN-WISE-ROMAN-METELSKY-LEWIS-NETZLEY 12
14
A B I L L
To amend sections 1751.02 to 1751.04, 1751.12, 16
1751.13, 3901.04, 3901.041, 3901.16, and 3924.10 18
and to enact sections 1751.521, 1751.73 to 19
1751.75, 1751.77 to 1751.86, 1753.01, 1753.03 to 21
1753.10, 1753.14, 1753.16, 1753.21, 1753.23,
1753.24, 1753.28, and 1753.30 of the Revised Code 22
to adopt the Physician-Health Plan Partnership 23
Act. 24
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 26
Section 1. That sections 1751.02, 1751.03, 1751.04, 28
1751.12, 1751.13, 3901.04, 3901.041, 3901.16, and 3924.10 be 29
amended and sections 1751.521, 1751.73, 1751.74, 1751.75, 30
1751.77, 1751.78, 1751.79, 1751.80, 1751.81, 1751.82, 1751.83, 31
1751.84, 1751.85, 1751.86, 1753.01, 1753.03, 1753.04, 1753.05, 32
1753.06, 1753.07, 1753.08, 1753.09, 1753.10, 1753.14, 1753.16, 34
1753.21, 1753.23, 1753.24, 1753.28, and 1753.30 of the Revised 36
Code be enacted to read as follows:
Sec. 1751.02. (A) Notwithstanding any law in this state 45
to the contrary, any corporation, as defined in section 1751.01 47
of the Revised Code, may apply to the superintendent of insurance 49
for a certificate of authority to establish and operate a health 50
insuring corporation. If the corporation applying for a 51
2
certificate of authority is a foreign corporation domiciled in a 52
state without laws similar to those of this chapter, the 54
corporation must form a domestic corporation to apply for,
obtain, and maintain a certificate of authority under this 55
chapter.
(B) No person shall establish, operate, or perform the 58
services of a health insuring corporation in this state without 60
obtaining a certificate of authority under this chapter. 61
(C) Except as provided by division (D) of this section, no 64
political subdivision or department, office, or institution of 65
this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of 66
this state, shall establish, operate, or perform the services of 67
a health insuring corporation. Nothing in this section shall be 70
construed to preclude a board of county commissioners, a county 71
board of mental retardation and developmental disabilities, an 72
alcohol and drug addiction services board, a board of alcohol, 73
drug addiction, and mental health services, or a community mental 74
health board, or a public entity formed by or on behalf of any of 75
these boards, from using managed care techniques in carrying out 76
the board's or public entity's duties pursuant to the 77
requirements of Chapters 307., 329., 340., and 5126. of the 79
Revised Code. However, no such board or public entity may 81
operate so as to compete in the private sector with health 82
insuring corporations holding certificates of authority under 83
this chapter.
(D) A corporation formed by or on behalf of a publicly 85
owned, operated, or funded hospital or health care facility may 86
apply to the superintendent for a certificate of authority under 88
division (A) of this section to establish and operate a health 89
insuring corporation.
(E) A health insuring corporation shall operate in this 92
state in compliance with this chapter AND CHAPTER 1753. OF THE 93
REVISED CODE, and with sections 3702.51 to 3702.62 of the Revised 95
3
Code, and shall operate in conformity with its filings with the 97
superintendent under this chapter, including filings made 98
pursuant to sections 1751.03, 1751.11, 1751.12, and 1751.31 of 99
the Revised Code. 101
(F) An insurer licensed under Title XXXIX of the Revised 105
Code need not obtain a certificate of authority as a health 106
insuring corporation to offer an open panel plan as long as the 107
providers and health care facilities participating in the open 108
panel plan receive their compensation directly from the insurer. 109
If the providers and health care facilities participating in the 110
open panel plan receive their compensation from any person other 111
than the insurer, or if the insurer offers a closed panel plan, 112
the insurer must obtain a certificate of authority as a health 113
insuring corporation.
(G) An intermediary organization need not obtain a 116
certificate of authority as a health insuring corporation, 117
regardless of the method of reimbursement to the intermediary 118
organization, as long as a health insuring corporation or a 120
self-insured employer maintains the ultimate responsibility to 121
assure delivery of all health care services required by the
contract between the health insuring corporation and the 122
subscriber and the laws of this state or between the self-insured 123
employer and its employees. 124
Nothing in this section shall be construed to require any 126
health care facility, provider, health delivery network, or 127
intermediary organization that contracts with a health insuring 128
corporation or self-insured employer, regardless of the method of 130
reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a 131
certificate of authority as a health insuring corporation under 132
this chapter, unless otherwise provided, in the case of contracts 134
with a self-insured employer, by operation of the "Employee 135
Retirement Income Security Act of 1974," 88 Stat. 829, 29 140
U.S.C.A. 1001, as amended. 142
4
(H) Any health delivery network doing business in this 145
state that is not required to obtain a certificate of authority 146
under this chapter shall certify to the superintendent annually, 147
not later than the first day of July, and shall provide a 149
statement signed by the highest ranking official which includes 150
the following information:
(1) The health delivery network's full name and the 152
address of its principal place of business; 153
(2) A statement that the health delivery network is not 155
required to obtain a certificate of authority under this chapter 156
to conduct its business. 157
(I) The superintendent shall not issue a certificate of 160
authority to a health insuring corporation that is a provider 161
sponsored organization unless all health care plans to be offered 162
by the health insuring corporation provide basic health care 163
services. Substantially all of the physicians and hospitals with 164
ownership or control of the provider sponsored organization, as 165
defined in division (W) of section 1751.01 of the Revised Code, 168
shall also be participating providers for the provision of basic 169
health care services for health care plans offered by the 170
provider sponsored organization. If a health insuring 171
corporation that is a provider sponsored organization offers 172
health care plans that do not provide basic health care services, 173
the health insuring corporation shall be deemed, for purposes of 174
section 1751.35 of the Revised Code, to have failed to 175
substantially comply with this chapter. 176
Except as specifically provided in this division and in 178
division (C) of section 1751.28 of the Revised Code, the 180
provisions of this chapter shall apply to all health insuring
corporations that are provider sponsored organizations in the 181
same manner that these provisions apply to all health insuring 182
corporations that are not provider sponsored organizations. 183
(J) Nothing in this section shall be construed to apply to 185
any multiple employer welfare arrangement operating pursuant to 186
5
Chapter 1739. of the Revised Code. 187
(K) Any person who violates division (B) of this section, 191
and any health delivery network that fails to comply with 192
division (H) of this section, is subject to the penalties set 193
forth in section 1751.45 of the Revised Code. 195
Sec. 1751.03. (A) Each application for a certificate of 205
authority under this chapter shall be verified by an officer or 206
authorized representative of the applicant, shall be in a format 207
prescribed by the superintendent of insurance, and shall set 208
forth or be accompanied by the following: 209
(1) A certified copy of the applicant's articles of 211
incorporation and all amendments to the articles of 212
incorporation; 213
(2) A copy of any regulations adopted for the government 215
of the corporation, any bylaws, and any similar documents, and a 216
copy of all amendments to these regulations, bylaws, and 217
documents. The corporate secretary shall certify that these 218
regulations, bylaws, documents, and amendments have been properly 220
adopted or approved.
(3) A list of the names, addresses, and official positions 223
of the persons responsible for the conduct of the applicant, 224
including all members of the board, the principal officers, and 225
the person responsible for completing or filing financial 226
statements with the department of insurance, accompanied by a 227
completed original biographical affidavit and release of 228
information for each of these persons on forms acceptable to the 229
department;
(4) A full and complete disclosure of the extent and 231
nature of any contractual or other financial arrangement between 232
the applicant and any provider or a person listed in division 233
(A)(3) of this section, including, but not limited to, a full and 235
complete disclosure of the financial interest held by any such 236
provider or person in any health care facility, provider, or 237
insurer that has entered into a financial relationship with the 238
6
health insuring corporation; 239
(5) A description of the applicant, its facilities, and 241
its personnel, including, but not limited to, the location, hours 243
of operation, and telephone numbers of all contracted facilities; 244
(6) The applicant's projected annual enrollee population 246
over a three-year period; 247
(7) A clear and specific description of the health care 249
plan or plans to be used by the applicant, including a 250
description of the proposed providers, procedures for accessing 251
care, and the form of all proposed and existing contracts 252
relating to the administration, delivery, or financing of health 253
care services; 254
(8) A copy of each type of evidence of coverage and 256
identification card or similar document to be issued to 257
subscribers; 258
(9) A copy of each type of individual or group policy, 260
contract, or agreement to be used; 261
(10) The schedule of the proposed contractual periodic 263
prepayments or premium rates, or both, accompanied by appropriate 264
supporting data; 265
(11) A financial plan which provides a three-year 267
projection of operating results, including the projected 268
expenses, income, and sources of working capital; 269
(12) The enrollee complaint procedure to be utilized as 271
required under section 1751.19 of the Revised Code; 274
(13) A description of the procedures and programs to be 276
implemented on an ongoing basis to assure the quality of health 277
care services delivered to enrollees, INCLUDING, IF APPLICABLE, A 278
DESCRIPTION OF A QUALITY ASSURANCE PROGRAM COMPLYING WITH THE 280
REQUIREMENTS OF SECTIONS 1751.73 TO 1751.75 OF THE REVISED CODE;
(14) A statement describing the geographic area or areas 282
to be served, by county; 283
(15) A copy of all solicitation documents; 285
(16) A balance sheet and other financial statements 287
7
showing the applicant's assets, liabilities, income, and other 288
sources of financial support; 289
(17) A description of the nature and extent of any 291
reinsurance program to be implemented, and a demonstration that 292
errors and omission insurance and, if appropriate, fidelity 293
insurance, will be in place upon the applicant's receipt of a 294
certificate of authority; 295
(18) Copies of all proposed or in force related-party or 297
intercompany agreements with an explanation of the financial 298
impact of these agreements on the applicant. If the applicant 299
intends to enter into a contract for managerial or administrative 301
services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed 302
description of the person to provide these services. The 304
description shall include that person's experience in managing or 305
administering health care plans, a copy of that person's most 306
recent audited financial statement, and a completed biographical 307
affidavit on a form acceptable to the superintendent for each of 308
that person's principal officers and board members and for any 309
additional employee to be directly involved in providing 310
managerial or administrative services to the health insuring 311
corporation. If the person to provide managerial or 312
administrative services is affiliated with the health insuring 313
corporation, the contract must provide for payment for services 314
based on actual costs.
(19) A statement from the applicant's board that the 316
admitted assets of the applicant have not been and will not be 317
pledged or hypothecated; 318
(20) A statement from the applicant's board that the 320
applicant will submit monthly financial statements during the 321
first year of operations; 322
(21) The name and address of the applicant's Ohio 325
statutory agent for service of process, notice, or demand; 326
(22) Copies of all documents the applicant filed with the 328
8
secretary of state; 329
(23) The location of those books and records of the 331
applicant that must be maintained in Ohio; 332
(24) The applicant's federal identification number, 334
corporate address, and mailing address; 335
(25) An internal and external organizational chart; 338
(26) A list of the assets representing the initial net 340
worth of the applicant; 341
(27) If the applicant has a parent company, the parent 343
company's guaranty, on a form acceptable to the superintendent, 344
that the applicant will maintain Ohio's minimum net worth. If no 347
parent company exists, a statement regarding the availability of 348
future funds if needed.
(28) The names and addresses of the applicant's actuary 350
and external auditors; 351
(29) If the applicant is a foreign corporation, a copy of 353
the most recent financial statements filed with the insurance 354
regulatory agency in the applicant's state of domicile; 355
(30) If the applicant is a foreign corporation, a 357
statement from the insurance regulatory agency of the applicant's 358
state of domicile stating that the regulatory agency has no 359
objection to the applicant applying for an Ohio license and that 360
the applicant is in good standing in the applicant's state of 361
domicile; 362
(31) Any other information that the superintendent may 364
require. 365
(B)(1) A health insuring corporation, unless otherwise 368
provided for in this chapter, shall file a timely notice with the 369
superintendent describing any change to the corporation's 370
articles of incorporation or regulations, or any major 371
modification to its operations as set out in the information 372
required by division (A) of this section that affects any of the 374
following:
(a) The solvency of the health insuring corporation; 377
9
(b) The health insuring corporation's continued provision 380
of services that it has contracted to provide; 381
(c) The manner in which the health insuring corporation 384
conducts its business.
(2) If the change or modification is to be the result of 386
an action to be taken by the health insuring corporation, the 387
notice shall be filed with the superintendent prior to the health 388
insuring corporation taking the action. The action shall be 390
deemed approved if the superintendent does not disapprove it 391
within sixty days of filing. 392
(C)(1) No health insuring corporation shall expand its 395
approved service area until a copy of the request for expansion, 396
accompanied by documentation of the network of providers, 397
enrollment projections, plan of operation, and any other changes 398
have been filed with the superintendent. 399
(2) Within ten calendar days after receipt of a complete 401
filing under division (C)(1) of this section, the superintendent 403
shall refer the appropriate jurisdictional issues to the director 404
of health pursuant to section 1751.04 of the Revised Code. 406
(3) Within seventy-five days after the superintendent's 408
receipt of a complete filing under division (C)(1) of this 410
section, the superintendent shall determine whether the plan for 411
expansion is lawful, fair, and reasonable. The superintendent 412
may not make a determination until the superintendent has 413
received the director's certification of compliance, which the 414
director shall furnish within forty-five days after referral 415
under division (C)(2) of this section. The director shall not 417
certify that the requirements of section 1751.04 of the Revised 418
Code are not met, unless the applicant has been given an 420
opportunity for a hearing as provided in division (D) of section 422
1751.04 of the Revised Code. The forty-five-day and 423
seventy-five-day review periods provided for in division (C)(3) 425
of this section shall cease to run as of the date on which the 426
notice of the applicant's right to request a hearing is mailed 427
10
and shall remain suspended until the director issues a final 428
certification. 429
(4) If the superintendent has not approved or disapproved 431
all or a portion of a service area expansion within the 432
seventy-five-day period provided for in division (C)(3) of this 434
section, the filing shall be deemed approved. 435
(5) Disapproval of all or a portion of the filing shall be 438
effected by written notice, which shall state the grounds for the 439
order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code. 440
Sec. 1751.04. (A) Upon the receipt by the superintendent 451
of insurance of a complete application for a certificate of 452
authority to establish or operate a health insuring corporation, 453
which application sets forth or is accompanied by the information 454
and documents required by division (A) of section 1751.03 of the 456
Revised Code, the superintendent shall transmit copies of the 458
application and accompanying documents to the director of health. 459
(B) The director shall review the application and 462
accompanying documents and make findings as to whether the 463
applicant for a certificate of authority has done all of the 464
following with respect to any basic health care services and 465
supplemental health care services to be furnished: 466
(1) Demonstrated the willingness and potential ability to 468
ensure that all basic health care services and supplemental 469
health care services described in the evidence of coverage will 471
be provided to all its enrollees as promptly as is appropriate 472
and in a manner that assures continuity; 473
(2) Made effective arrangements to ensure that its 475
enrollees have reliable access to qualified providers in those 476
specialties that are generally available in the geographic area 477
or areas to be served by the applicant and that are necessary to 478
provide all basic health care services and supplemental health 479
care services described in the evidence of coverage; 481
(3) Made appropriate arrangements for the availability of 483
11
short-term health care services in emergencies within the 484
geographic area or areas to be served by the applicant, 485
twenty-four hours per day, seven days per week, and for the 486
provision of adequate coverage whenever an out-of-area emergency 487
arises; 488
(4) Made appropriate arrangements for an ongoing 490
evaluation and assurance of the quality of health care services 491
provided to enrollees, INCLUDING, IF APPLICABLE, THE DEVELOPMENT 492
OF A QUALITY ASSURANCE PROGRAM COMPLYING WITH THE REQUIREMENTS OF 494
SECTIONS 1751.73 TO 1751.75 OF THE REVISED CODE, and the adequacy
of the personnel, facilities, and equipment by or through which 495
the services are rendered; 496
(5) Developed a procedure to gather and report statistics 498
relating to the cost and effectiveness of its operations, the 499
pattern of utilization of its services, and the quality, 500
availability, and accessibility of its services. 501
(C) Within ninety days of the director's receipt of the 503
application for issuance of a certificate of authority, the 505
director shall certify to the superintendent whether or not the 506
applicant meets the requirements of division (B) of this section 507
and sections 3702.51 to 3702.62 of the Revised Code. If the 508
director certifies that the applicant does not meet these 509
requirements, the director shall specify in what respects it is 510
deficient. However, the director shall not certify that the 511
requirements of this section are not met unless the applicant has 512
been given an opportunity for a hearing. 513
(D) If the applicant requests a hearing, the director 516
shall hold a hearing before certifying that the applicant does 517
not meet the requirements of this section. The hearing shall be 518
held in accordance with Chapter 119. of the Revised Code. 520
(E) The ninety-day review period provided for under 523
division (C) of this section shall cease to run as of the date on 525
which the notice of the applicant's right to request a hearing is 526
mailed and shall remain suspended until the director issues a 527
12
final certification order.
Sec. 1751.12. (A)(1) No contractual periodic prepayment 537
and no premium rate for nongroup and conversion policies for 538
health care services, or any amendment to them, may be used by 539
any health insuring corporation at any time until the contractual 540
periodic prepayment and premium rate, or amendment, have been 541
filed with the superintendent of insurance, and shall not be 542
effective until the expiration of sixty days after their filing 543
unless the superintendent sooner gives approval. The 544
superintendent shall disapprove the filing, if the superintendent 545
determines within the sixty-day period that the contractual 546
periodic prepayment or premium rate, or amendment, is not in 547
accordance with sound actuarial principles or is not reasonably 548
related to the applicable coverage and characteristics of the 549
applicable class of enrollees. The superintendent shall notify 550
the health insuring corporation of the disapproval, and it shall 551
thereafter be unlawful for the health insuring corporation to use 552
the contractual periodic prepayment or premium rate, or 553
amendment.
(2) No contractual periodic prepayment for group policies 556
for health care services shall be used until the contractual 557
periodic prepayment has been filed with the superintendent. The 558
superintendent may reject a filing made under division (A)(2) of 559
this section at any time, with at least thirty days' written 560
notice to a health insuring corporation, if the contractual 561
periodic prepayment is not in accordance with sound actuarial 563
principles or is not reasonably related to the applicable 564
coverage and characteristics of the applicable class of 565
enrollees.
(3) At any time, the superintendent, upon at least thirty 567
days' written notice to a health insuring corporation, may 568
withdraw the approval given under division (A)(1) of this 569
section, deemed or actual, of any contractual periodic prepayment 571
or premium rate, or amendment, based on information that either 572
13
of the following applies:
(a) The contractual periodic prepayment or premium rate, 575
or amendment, is not in accordance with sound actuarial 576
principles.
(b) The contractual periodic prepayment or premium rate, 579
or amendment, is not reasonably related to the applicable 580
coverage and characteristics of the applicable class of 581
enrollees.
(4) Any disapproval under division (A)(1) of this section, 583
any rejection of a filing made under division (A)(2) of this 585
section, or any withdrawal of approval under division (A)(3) of 586
this section, shall be effected by a written notice, which shall 587
state the specific basis for the disapproval, rejection, or 588
withdrawal and shall be issued in accordance with Chapter 119. of 589
the Revised Code. 590
(B) Notwithstanding division (A) of this section, a health 593
insuring corporation may use a contractual periodic prepayment or 594
premium rate for policies used for the coverage of beneficiaries 595
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 597
620 (1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare 599
risk contract or medicare cost contract, or for policies used for 600
the coverage of beneficiaries enrolled in the federal employees 601
health benefits program pursuant to 5 U.S.C.A. 8905, or for 604
policies used for the coverage of beneficiaries enrolled in Title 605
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 607
U.S.C.A. 301, as amended, known as the medical assistance program 610
or medicaid, provided by the Ohio department of human services 611
under Chapter 5111. of the Revised Code, or for policies used for 612
the coverage of beneficiaries under any other federal health care 613
program regulated by a federal regulatory body, if both of the 614
following apply: 615
(1) The contractual periodic prepayment or premium rate 617
has been approved by the United States department of health and 618
human services, the United States office of personnel management, 620
14
or the Ohio department of human services.
(2) The contractual periodic prepayment or premium rate is 622
filed with the superintendent prior to use and is accompanied by 623
documentation of approval from the United States department of 625
health and human services, the United States office of personnel 627
management, or the Ohio department of human services. 629
(C) The administrative expense portion of all contractual 632
periodic prepayment or premium rate filings submitted to the 633
superintendent for review must reflect the actual cost of 634
administering the product. The superintendent may require that 635
the administrative expense portion of the filings be itemized and 636
supported.
(D)(1) Copayments and deductibles must be reasonable and 639
must not be a barrier to the necessary utilization of services by 640
enrollees.
(2) A health insuring corporation may not impose copayment 643
charges on basic health care services that exceed thirty per cent 644
of the total cost of providing any single covered health care 645
service, except for PHYSICIAN OFFICE VISITS, emergency health 646
services, and urgent care services. The total cost of providing 647
a health care service is the cost to the health insuring 648
corporation of providing the health care service to the enrollee 649
ITS ENROLLEES as reduced by any applicable provider discount. An 652
open panel plan may not impose copayments on out-of-network
benefits that exceed fifty per cent of the total cost of 653
providing any single covered health care service. 654
(3) To ensure that copayments are not a barrier to the 656
utilization of basic health care services, a health insuring 657
corporation may not impose, in any contract year, on any 658
subscriber or enrollee, copayments that exceed two hundred per 659
cent of the total annual premium rate to the subscriber or 660
enrollees. This limitation of two hundred per cent does not 662
include any reasonable copayments that are not a barrier to the 663
necessary utilization of health care services by enrollees and 664
15
that are imposed on physician office visits, emergency health 665
services, urgent care services, supplemental health care 666
services, or specialty health care services.
(E) A health insuring corporation shall not impose 669
lifetime maximums on basic health care services. However, a 670
health insuring corporation may establish a benefit limit for 671
inpatient hospital services that are provided pursuant to a 672
policy, contract, certificate, or agreement for supplemental 673
health care services.
Sec. 1751.13. (A)(1)(a) A health insuring corporation 683
shall, either directly or indirectly, enter into contracts for 684
the provision of health care services with a sufficient number 685
and types of providers and health care facilities to ensure that 686
all covered health care services will be accessible to enrollees 687
from a contracted provider or health care facility. 688
(b) A HEALTH INSURING CORPORATION SHALL NOT REFUSE TO 691
CONTRACT WITH A PHYSICIAN FOR THE PROVISION OF HEALTH CARE
SERVICES OR REFUSE TO RECOGNIZE A PHYSICIAN AS A SPECIALIST ON 692
THE BASIS THAT THE PHYSICIAN ATTENDED AN EDUCATIONAL PROGRAM OR A 694
RESIDENCY PROGRAM APPROVED OR CERTIFIED BY THE AMERICAN 695
OSTEOPATHIC ASSOCIATION. A HEALTH INSURING CORPORATION SHALL NOT 696
REFUSE TO CONTRACT WITH A HEALTH CARE FACILITY FOR THE PROVISION 697
OF HEALTH CARE SERVICES ON THE BASIS THAT THE HEALTH CARE 698
FACILITY IS CERTIFIED OR ACCREDITED BY THE AMERICAN OSTEOPATHIC 700
ASSOCIATION OR THAT THE HEALTH CARE FACILITY IS AN OSTEOPATHIC 701
HOSPITAL AS DEFINED IN SECTION 3702.51 OF THE REVISED CODE. 704
(c) NOTHING IN DIVISION (A)(1)(b) OF THIS SECTION SHALL BE 708
CONSTRUED TO REQUIRE A HEALTH INSURING CORPORATION TO MAKE A 709
BENEFIT PAYMENT UNDER A CLOSED PANEL PLAN TO A PHYSICIAN OR 710
HEALTH CARE FACILITY WITH WHICH THE HEALTH INSURING CORPORATION 711
DOES NOT HAVE A CONTRACT, PROVIDED THAT NONE OF THE BASES SET 712
FORTH IN THAT DIVISION ARE USED AS A REASON FOR FAILING TO MAKE A 713
BENEFIT PAYMENT.
(2) When a health insuring corporation is unable to 715
16
provide a covered health care service from a contracted provider 716
or health care facility, the health insuring corporation must 717
provide that health care service from a noncontracted provider or 719
health care facility consistent with the terms of the enrollee's 720
policy, contract, certificate, or agreement. The health insuring 721
corporation shall either ensure that the health care service be 722
provided at no greater cost to the enrollee than if the enrollee 723
had obtained the health care service from a contracted provider 724
or health care facility, or make other arrangements acceptable to 725
the superintendent of insurance. 726
(3) Nothing in this section shall prohibit a health 728
insuring corporation from entering into contracts with 729
out-of-state providers or health care facilities that are 730
licensed, certified, accredited, or otherwise authorized in that 731
state. 732
(B)(1) A health insuring corporation shall, either 735
directly or indirectly, enter into contracts with all providers 736
and health care facilities through which health care services are 737
provided to its enrollees.
(2) A health insuring corporation, upon written request, 739
shall assist its contracted providers in finding stop-loss or 740
reinsurance carriers.
(C) A health insuring corporation shall file an annual 742
certificate with the superintendent certifying that all provider 743
contracts and contracts with health care facilities through which 744
health care services are being provided contain the following: 745
(1) A description of the method by which the provider or 747
health care facility will be notified of the specific health care 749
services for which the provider or health care facility will be 750
responsible, including any limitations or conditions on such 751
services;
(2) The specific hold harmless provision specifying 753
protection of enrollees set forth as follows: 754
"[Provider/Health Care Facility< agrees that in no event, 757
17
including but not limited to nonpayment by the health insuring 758
corporation, insolvency of the health insuring corporation, or 759
breach of this agreement, shall [Provider/Health Care Facility< 761
bill, charge, collect a deposit from, seek remuneration or 762
reimbursement from, or have any recourse against, a subscriber, 763
enrollee, person to whom health care services have been provided, 765
or person acting on behalf of the covered enrollee, for health 766
care services provided pursuant to this agreement. This does not 767
prohibit [Provider/Health Care Facility< from collecting 768
co-insurance, deductibles, or copayments as specifically provided 770
in the evidence of coverage, or fees for uncovered health care 771
services delivered on a fee-for-service basis to persons 772
referenced above, nor from any recourse against the health 773
insuring corporation or its successor."
(3) Provisions requiring the provider or health care 775
facility to continue to provide covered health care services to 776
enrollees in the event of the health insuring corporation's 777
insolvency or discontinuance of operations. The provisions shall 779
require the provider or health care facility to continue to 780
provide covered health care services to enrollees as needed to 781
complete any medically necessary procedures commenced but 782
unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. If an enrollee is 783
receiving necessary inpatient care at a hospital, the provisions 784
may limit the required provision of covered health care services 785
relating to that inpatient care in accordance with division 786
(D)(3) of section 1751.11 of the Revised Code, and may also limit 788
such required provision of covered health care services to the 789
period ending thirty days after the health insuring corporation's 790
insolvency or discontinuance of operations. 791
The provisions required by division (C)(3) of this section 794
shall not require any provider or health care facility to 795
continue to provide any covered health care service after the
occurrence of any of the following: 796
18
(a) The end of the thirty-day period following the entry 798
of a liquidation order under Chapter 3903. of the Revised Code; 800
(b) The end of the enrollee's period of coverage for a 802
contractual prepayment or premium; 803
(c) The enrollee obtains equivalent coverage with another 805
health insuring corporation or insurer, or the enrollee's 806
employer obtains such coverage for the enrollee; 807
(d) The enrollee or the enrollee's employer terminates 809
coverage under the contract; 810
(e) A liquidator effects a transfer of the health insuring 813
corporation's obligations under the contract under division 814
(A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and 816
responsibilities of the health insuring corporation, and of the 817
contracted providers and health care facilities, with respect to 818
administrative policies and programs, including, but not limited 819
to, payments systems, utilization review, quality ASSURANCE, 820
assessment, and improvement programs, credentialing, 821
confidentiality requirements, and any applicable federal or state 822
programs; 823
(5) A provision regarding the availability and 825
confidentiality of those health records maintained by providers 826
and health care facilities to monitor and evaluate the quality of 828
care, to conduct evaluations and audits, and to determine on a 829
concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees. 830
The provision shall include terms requiring the provider or 831
health care facility to make these health records available to 832
appropriate state and federal authorities involved in assessing 833
the quality of care or in investigating the grievances or 834
complaints of enrollees, and requiring the provider or health 835
care facility to comply with applicable state and federal laws 836
related to the confidentiality of medical or health records. 838
(6) A provision that states that contractual rights and 840
19
responsibilities may not be assigned or delegated by the provider 842
or health care facility without the prior written consent of the 843
health insuring corporation;
(7) A provision requiring the provider or health care 845
facility to maintain adequate professional liability and 846
malpractice insurance. The provision shall also require the 847
provider or health care facility to notify the health insuring 848
corporation not more than ten days after the provider's or health 850
care facility's receipt of notice of any reduction or
cancellation of such coverage. 851
(8) A provision requiring the provider or health care 853
facility to observe, protect, and promote the rights of enrollees 855
as patients;
(9) A provision requiring the provider or health care 857
facility to provide health care services without discrimination 858
on the basis of a patient's participation in the health care 859
plan, age, sex, ethnicity, religion, sexual preference, health 860
status, or disability, and without regard to the source of 861
payments made for health care services rendered to a patient. 862
This requirement shall not apply to circumstances when the 863
provider or health care facility appropriately does not render 864
services due to limitations arising from the provider's or health 866
care facility's lack of training, experience, or skill, or due to 867
licensing restrictions.
(10) A provision containing the specifics of any 869
obligation on the provider or health care facility to provide, or 871
to arrange for the provision of, covered health care services
twenty-four hours per day, seven days per week; 872
(11) A provision setting forth procedures for the 874
resolution of disputes arising out of the contract; 875
(12) A provision stating that the hold harmless provision 877
required by division (C)(2) of this section shall survive the 879
termination of the contract with respect to services covered and 880
provided under the contract during the time the contract was in 881
20
effect, regardless of the reason for the termination, including
the insolvency of the health insuring corporation; 882
(13) A provision requiring those terms that are used in 884
the contract and that are defined by this chapter, be used in the 886
contract in a manner consistent with those definitions. 887
(D)(1) No health insuring corporation contract with a 890
provider or health care facility shall do either CONTAIN ANY of 891
the following:
(1) Offer (a) A PROVISION THAT DIRECTLY OR INDIRECTLY 893
OFFERS an inducement to the provider or health care facility, 895
directly or indirectly, to reduce or limit medically necessary 896
health care services to a covered enrollee;
(2) Penalize (b) A PROVISION THAT PENALIZES a provider or 899
health care facility that assists an enrollee to seek a 900
reconsideration of the health insuring corporation's decision to 901
deny or limit benefits to the enrollee; 902
(c) A PROVISION THAT LIMITS OR OTHERWISE RESTRICTS THE 905
PROVIDER'S OR HEALTH CARE FACILITY'S ETHICAL AND LEGAL
RESPONSIBILITY TO FULLY ADVISE ENROLLEES ABOUT THEIR MEDICAL 906
CONDITION AND ABOUT MEDICALLY APPROPRIATE TREATMENT OPTIONS; 908
(d) A PROVISION THAT PENALIZES A PROVIDER OR HEALTH CARE 911
FACILITY FOR PRINCIPALLY ADVOCATING FOR MEDICALLY NECESSARY 912
HEALTH CARE SERVICES;
(e) A PROVISION THAT PENALIZES A PROVIDER OR HEALTH CARE 914
FACILITY FOR PROVIDING INFORMATION OR TESTIMONY TO A LEGISLATIVE 915
OR REGULATORY BODY OR AGENCY. THIS SHALL NOT BE CONSTRUED TO 916
PROHIBIT A HEALTH INSURING CORPORATION FROM PENALIZING A PROVIDER 918
OR HEALTH CARE FACILITY THAT PROVIDES INFORMATION OR TESTIMONY 919
THAT IS LIBELOUS OR SLANDEROUS OR THAT DISCLOSES TRADE SECRETS 920
WHICH THE PROVIDER OR HEALTH CARE FACILITY HAS NO PRIVILEGE OR 921
PERMISSION TO DISCLOSE.
(2) NOTHING IN THIS DIVISION SHALL BE CONSTRUED TO 923
PROHIBIT A HEALTH INSURING CORPORATION FROM DOING EITHER OF THE 924
FOLLOWING: 925
21
(a) MAKING A DETERMINATION NOT TO REIMBURSE OR PAY FOR A 928
PARTICULAR MEDICAL TREATMENT OR OTHER HEALTH CARE SERVICE; 929
(b) ENFORCING REASONABLE PEER REVIEW OR UTILIZATION REVIEW 932
PROTOCOLS, OR DETERMINING WHETHER A PARTICULAR PROVIDER OR HEALTH 933
CARE FACILITY HAS COMPLIED WITH THESE PROTOCOLS. 934
(E) Any contract between a health insuring corporation and 937
an intermediary organization shall clearly specify that the 938
health insuring corporation must approve or disapprove the 939
participation of any provider or health care facility with which 940
the intermediary organization contracts. 941
(F) If an intermediary organization that is not a health 943
delivery network contracting solely with self-insured employers 944
subcontracts with a provider or health care facility, the 945
subcontract with the provider or health care facility shall do 946
all of the following:
(1) Contain the provisions required by divisions (C) and 949
(G) of this section, as made applicable to an intermediary 950
organization, without the inclusion of inducements or penalties 951
described in division (D) of this section; 952
(2) Acknowledge that the health insuring corporation is a 954
third-party beneficiary to the agreement; 955
(3) Acknowledge the health insuring corporation's role in 957
approving the participation of the provider or health care 958
facility, pursuant to division (E) of this section. 960
(G) Any provider contract or contract with a health care 963
facility shall clearly specify the health insuring corporation's 964
statutory responsibility to monitor and oversee the offering of 965
covered health care services to its enrollees. 966
(H)(1) A health insuring corporation shall maintain its 969
provider contracts and its contracts with health care facilities 970
at one or more of its places of business in this state, and shall 971
provide copies of these contracts to facilitate regulatory review 972
upon written notice by the superintendent of insurance. 973
(2) Any contract with an intermediary organization shall 975
22
include provisions requiring the intermediary organization to 976
provide the superintendent with regulatory access to all books, 977
records, financial information, and documents related to the 978
provision of health care services to subscribers and enrollees 979
under the contract. The contract shall require the intermediary 980
organization to maintain such books, records, financial 981
information, and documents at its principal place of business in 982
this state and to preserve them for at least three years in a 983
manner that facilitates regulatory review. 984
(I) A health insuring corporation shall provide notice of 987
the termination of any contract with a primary care physician or 988
hospital.
(J) Divisions (A) and (B) of this section do not apply to 991
any health insuring corporation that, on the effective date of 992
this section JUNE 4, 1997, holds a certificate of authority or 993
license to operate under Chapter 1740. of the Revised Code. 995
(K) NOTHING IN THIS SECTION SHALL RESTRICT THE GOVERNING 997
BODY OF A HOSPITAL FROM EXERCISING THE AUTHORITY GRANTED IT 998
PURSUANT TO SECTION 3701.351 OF THE REVISED CODE. 999
Sec. 1751.521. IF AN ENROLLEE SIGNS A MEDICAL INFORMATION 1,001
RELEASE UPON THE REQUEST OF A HEALTH INSURING CORPORATION, THE 1,002
RELEASE SHALL CLEARLY EXPLAIN WHAT INFORMATION MAY BE DISCLOSED 1,003
UNDER THE TERMS OF THE RELEASE. IF A HEALTH INSURING CORPORATION 1,004
UTILIZES THIS RELEASE TO REQUEST MEDICAL INFORMATION FROM A 1,005
HEALTH CARE FACILITY OR PROVIDER, THE HEALTH INSURING CORPORATION
SHALL PROVIDE A COPY OF THE ENROLLEE'S RELEASE TO THE HEALTH CARE 1,006
FACILITY OR PROVIDER, UPON REQUEST. 1,007
Sec. 1751.73. EACH HEALTH INSURING CORPORATION PROVIDING 1,010
BASIC HEALTH CARE SERVICES SHALL IMPLEMENT A QUALITY ASSURANCE 1,011
PROGRAM FOR USE IN CONNECTION WITH THOSE POLICIES, CONTRACTS, AND 1,012
AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES. EACH HEALTH 1,013
INSURING CORPORATION REQUIRED TO IMPLEMENT A QUALITY ASSURANCE 1,014
PROGRAM SHALL ANNUALLY FILE A CERTIFICATE WITH THE SUPERINTENDENT 1,015
OF INSURANCE CERTIFYING THAT ITS QUALITY ASSURANCE PROGRAM DOES 1,016
23
ALL OF THE FOLLOWING:
(A) IDENTIFIES A CORPORATE BOARD OR COMMITTEE OR 1,018
DESIGNATES AN EXECUTIVE STAFF PERSON RESPONSIBLE FOR PROGRAM 1,019
IMPLEMENTATION AND COMPLIANCE;
(B) INCLUDES A PROCESS ENABLING THE SELECTION AND 1,021
RETENTION OF QUALITY PROVIDERS AND HEALTH CARE FACILITIES THROUGH 1,022
CREDENTIALING, RECREDENTIALING, AND MONITORING PROCEDURES; 1,023
(C) PROVIDES FOR ONGOING MONITORING OF THE QUALITY 1,025
ASSURANCE PROGRAM; 1,026
(D) ASSURES A PROCESS FOR COMPLIANCE BY ANY ENTITY OR 1,028
ENTITIES WITH WHICH THE HEALTH INSURING CORPORATION CONTRACTS FOR 1,029
SERVICES;
(E) INCLUDES A PROCESS TO TAKE REMEDIAL ACTION TO CORRECT 1,031
QUALITY PROBLEMS. 1,032
Sec. 1751.74. (A) TO IMPLEMENT A QUALITY ASSURANCE 1,034
PROGRAM REQUIRED BY SECTION 1715.73 OF THE REVISED CODE, A HEALTH 1,035
INSURING CORPORATION SHALL DO BOTH OF THE FOLLOWING: 1,036
(1) DEVELOP AND MAINTAIN THE APPROPRIATE INFRASTRUCTURE 1,039
AND DISCLOSURE SYSTEMS NECESSARY TO MEASURE AND REPORT, ON A 1,040
REGULAR BASIS, THE QUALITY OF HEALTH CARE SERVICES PROVIDED TO 1,041
ENROLLEES, BASED ON A SYSTEMATIC COLLECTION, ANALYSIS, AND 1,042
REPORTING OF RELEVANT DATA. THE HEALTH INSURING CORPORATION 1,043
SHALL ASSURE THAT A COMMITTEE THAT INCLUDES PARTICIPATING 1,044
PHYSICIANS HAVE THE OPPORTUNITY TO PARTICIPATE IN DEVELOPING, 1,045
IMPLEMENTING, AND EVALUATING THE QUALITY ASSURANCE PROGRAM AND 1,047
ALL OTHER PROGRAMS IMPLEMENTED BY THE HEALTH INSURING CORPORATION
THAT RELATE TO THE UTILIZATION OF HEALTH CARE SERVICES. A 1,049
COMMITTEE THAT INCLUDES PARTICIPATING PHYSICIANS SHALL ALSO HAVE 1,050
THE OPPORTUNITY TO PARTICIPATE IN THE DERIVATION OF DATA 1,051
ASSESSMENTS, STATISTICAL ANALYSES, AND OUTCOME INTERPRETATIONS 1,053
FROM PROGRAMS MONITORING THE UTILIZATION OF HEALTH CARE SERVICES. 1,054
(2) DEVELOP AND MAINTAIN AN ORGANIZATIONAL PROGRAM FOR 1,057
DESIGNING, MEASURING, ASSESSING, AND IMPROVING THE PROCESSES AND 1,058
OUTCOMES OF HEALTH CARE.
24
(B) A QUALITY ASSURANCE PROGRAM SHALL: 1,060
(1) ESTABLISH AN INTERNAL SYSTEM CAPABLE OF IDENTIFYING 1,062
OPPORTUNITIES TO IMPROVE HEALTH CARE, WHICH SYSTEM IS STRUCTURED 1,063
TO IDENTIFY PRACTICES THAT RESULT IN IMPROVED HEALTH CARE 1,064
OUTCOMES, TO IDENTIFY PROBLEMATIC UTILIZATION PATTERNS, AND TO 1,065
IDENTIFY THOSE PROVIDERS THAT MAY BE RESPONSIBLE FOR EITHER 1,066
EXEMPLARY OR PROBLEMATIC PATTERNS. THE QUALITY ASSURANCE PROGRAM 1,067
SHALL USE THE FINDINGS GENERATED BY THE SYSTEM TO WORK ON A 1,069
CONTINUING BASIS WITH PARTICIPATING PROVIDERS AND OTHER STAFF TO 1,070
IMPROVE THE QUALITY OF HEALTH CARE SERVICES PROVIDED TO 1,072
ENROLLEES.
(2) DEVELOP A WRITTEN STATEMENT OF ITS OBJECTIVES, LINES 1,074
OF AUTHORITY AND ACCOUNTABILITY, EVALUATION TOOLS, AND 1,075
PERFORMANCE IMPROVEMENT ACTIVITIES; 1,076
(3) REQUIRE AN ANNUAL EFFECTIVENESS REVIEW OF THE PROGRAM; 1,079
(4) PROVIDE A DESCRIPTION OF HOW THE HEALTH INSURING 1,082
CORPORATION INTENDS TO DO ALL OF THE FOLLOWING: 1,083
(a) ANALYZE BOTH PROCESSES AND OUTCOMES OF HEALTH CARE, 1,085
INCLUDING FOCUSED REVIEW OF INDIVIDUAL CASES AS APPROPRIATE, TO 1,087
DISCERN THE CAUSES OF VARIATION;
(b) IDENTIFY THE TARGETED DIAGNOSES AND TREATMENTS TO BE 1,089
REVIEWED BY THE QUALITY ASSURANCE PROGRAM EACH YEAR, BASED ON 1,090
CONSIDERATION OF PRACTICES AND DIAGNOSES THAT AFFECT A 1,091
SUBSTANTIAL NUMBER OF THE HEALTH INSURING CORPORATION'S ENROLLEES 1,092
OR THAT COULD PLACE ENROLLEES AT SERIOUS RISK; 1,093
(c) USE A RANGE OF APPROPRIATE METHODS TO ANALYZE QUALITY 1,095
OF HEALTH CARE, INCLUDING COLLECTION AND ANALYSIS OF INFORMATION 1,097
ON OVER-UTILIZATION AND UNDER-UTILIZATION OF HEALTH CARE 1,098
SERVICES; EVALUATION OF COURSES OF TREATMENT AND OUTCOMES BASED 1,100
ON CURRENT MEDICAL RESEARCH, KNOWLEDGE, STANDARDS, AND PRACTICE
GUIDELINES; AND COLLECTION AND ANALYSIS OF INFORMATION SPECIFIC 1,101
TO ENROLLEES OR PROVIDERS; 1,102
(d) COMPARE QUALITY ASSURANCE PROGRAM FINDINGS WITH PAST 1,104
PERFORMANCE, INTERNAL GOALS, AND EXTERNAL STANDARDS; 1,106
25
(e) MEASURE THE PERFORMANCE OF PARTICIPATING PROVIDERS AND 1,108
CONDUCT PEER REVIEW ACTIVITIES; 1,109
(f) UTILIZE TREATMENT PROTOCOLS AND PRACTICE PARAMETERS 1,111
DEVELOPED WITH APPROPRIATE CLINICAL INPUT; 1,112
(g) IMPLEMENT IMPROVEMENT STRATEGIES RELATED TO QUALITY 1,114
ASSURANCE PROGRAM FINDINGS; 1,115
(h) EVALUATE PERIODICALLY, BUT NOT LESS THAN ANNUALLY, THE 1,117
EFFECTIVENESS OF THE IMPROVEMENT STRATEGIES. 1,118
Sec. 1751.75. A HEALTH INSURING CORPORATION MAY PRESENT 1,120
EVIDENCE OF COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1751.73 1,121
AND 1751.74 OF THE REVISED CODE BY SUBMITTING CERTIFICATION TO 1,122
THE SUPERINTENDENT OF INSURANCE OF ITS ACCREDITATION BY AN 1,123
INDEPENDENT, PRIVATE ACCREDITING ORGANIZATION, SUCH AS THE
NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION ON 1,124
ACCREDITATION OF HEALTH CARE ORGANIZATIONS, OR THE AMERICAN 1,125
ACCREDITATION HEALTHCARE COMMISSION/UTILIZATION REVIEW 1,127
ACCREDITATION COMMISSION. THE SUPERINTENDENT, UPON REVIEW OF THE 1,128
ORGANIZATION'S ACCREDITATION PROCESS, MAY DETERMINE THAT SUCH 1,129
ACCREDITATION CONSTITUTES COMPLIANCE BY THE HEALTH INSURING 1,130
CORPORATION WITH THE REQUIREMENTS OF THESE SECTIONS. 1,131
Sec. 1751.77. AS USED IN SECTIONS 1751.77 TO 1751.86 OF 1,133
THE REVISED CODE, UNLESS OTHERWISE SPECIFICALLY PROVIDED: 1,134
(A) "ADVERSE DETERMINATION" MEANS A DETERMINATION BY A 1,136
HEALTH INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,137
ORGANIZATION THAT AN ADMISSION, AVAILABILITY OF CARE, CONTINUED 1,139
STAY, OR OTHER HEALTH CARE SERVICE COVERED UNDER A POLICY, 1,140
CONTRACT, OR AGREEMENT OF THE HEALTH INSURING CORPORATION HAS 1,142
BEEN REVIEWED AND, BASED UPON THE INFORMATION PROVIDED, THE 1,143
HEALTH CARE SERVICE DOES NOT MEET THE HEALTH INSURING 1,145
CORPORATION'S REQUIREMENTS FOR BENEFIT PAYMENT, AND IS THEREFORE 1,146
DENIED, REDUCED, OR TERMINATED.
(B) "AMBULATORY REVIEW" MEANS UTILIZATION REVIEW OF HEALTH 1,148
CARE SERVICES PERFORMED OR PROVIDED IN AN OUTPATIENT SETTING. 1,149
(C) "CASE MANAGEMENT" MEANS A COORDINATED SET OF 1,151
26
ACTIVITIES CONDUCTED FOR INDIVIDUAL PATIENT MANAGEMENT OF 1,152
SERIOUS, COMPLICATED, PROTRACTED, OR OTHER SPECIFIED HEALTH 1,153
CONDITIONS.
(D) "CERTIFICATION" MEANS A DETERMINATION BY A HEALTH 1,155
INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,157
ORGANIZATION THAT AN ADMISSION, AVAILABILITY OF CARE, CONTINUED 1,158
STAY, OR OTHER HEALTH CARE SERVICE COVERED UNDER A POLICY, 1,159
CONTRACT, OR AGREEMENT OF THE HEALTH INSURING CORPORATION HAS 1,161
BEEN REVIEWED AND, BASED UPON THE INFORMATION PROVIDED, THE 1,162
HEALTH CARE SERVICE SATISFIES THE HEALTH INSURING CORPORATION'S 1,163
REQUIREMENTS FOR BENEFIT PAYMENT. 1,164
(E) "CLINICAL PEER" MEANS A PHYSICIAN WHEN AN EVALUATION 1,167
IS TO BE MADE OF THE CLINICAL APPROPRIATENESS OF HEALTH CARE 1,168
SERVICES PROVIDED BY A PHYSICIAN. IF AN EVALUATION IS TO BE MADE 1,169
OF THE CLINICAL APPROPRIATENESS OF HEALTH CARE SERVICES PROVIDED 1,170
BY A PROVIDER WHO IS NOT A PHYSICIAN, "CLINICAL PEER" MEANS 1,171
EITHER A PHYSICIAN OR A PROVIDER HOLDING THE SAME LICENSE AS THE 1,172
PROVIDER WHO PROVIDED THE HEALTH CARE SERVICES. 1,173
(F) "CLINICAL REVIEW CRITERIA" MEANS THE WRITTEN SCREENING 1,175
PROCEDURES, DECISION ABSTRACTS, CLINICAL PROTOCOLS, AND PRACTICE 1,176
GUIDELINES USED BY A HEALTH INSURING CORPORATION TO DETERMINE THE 1,177
NECESSITY AND APPROPRIATENESS OF HEALTH CARE SERVICES. 1,179
(G) "CONCURRENT REVIEW" MEANS UTILIZATION REVIEW CONDUCTED 1,181
DURING A PATIENT'S HOSPITAL STAY OR COURSE OF TREATMENT. 1,182
(H) "DISCHARGE PLANNING" MEANS THE FORMAL PROCESS FOR 1,184
DETERMINING, PRIOR TO A PATIENT'S DISCHARGE FROM A HEALTH CARE 1,185
FACILITY, THE COORDINATION AND MANAGEMENT OF THE CARE THAT THE 1,187
PATIENT IS TO RECEIVE FOLLOWING DISCHARGE FROM A HEALTH CARE 1,188
FACILITY. 1,189
(I) "PARTICIPATING PROVIDER" MEANS A PROVIDER OR HEALTH 1,191
CARE FACILITY THAT, UNDER A CONTRACT WITH A HEALTH INSURING 1,193
CORPORATION OR WITH ITS CONTRACTOR OR SUBCONTRACTOR, HAS AGREED 1,195
TO PROVIDE HEALTH CARE SERVICES TO ENROLLEES WITH AN EXPECTATION
OF RECEIVING PAYMENT, OTHER THAN COINSURANCE, COPAYMENTS, OR 1,196
27
DEDUCTIBLES, DIRECTLY OR INDIRECTLY FROM THE HEALTH INSURING 1,197
CORPORATION.
(J) "PHYSICIAN" MEANS A PROVIDER AUTHORIZED UNDER CHAPTER 1,200
4731. OF THE REVISED CODE TO PRACTICE MEDICINE AND SURGERY OR 1,203
OSTEOPATHIC MEDICINE AND SURGERY.
(K) "PROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW THAT IS 1,205
CONDUCTED PRIOR TO AN ADMISSION OR A COURSE OF TREATMENT. 1,206
(L) "RETROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW OF 1,208
MEDICAL NECESSITY THAT IS CONDUCTED AFTER HEALTH CARE SERVICES 1,209
HAVE BEEN PROVIDED TO A PATIENT. "RETROSPECTIVE REVIEW" DOES NOT 1,211
INCLUDE THE REVIEW OF A CLAIM THAT IS LIMITED TO AN EVALUATION OF 1,212
REIMBURSEMENT LEVELS, VERACITY OF DOCUMENTATION, ACCURACY OF 1,213
CODING, OR ADJUDICATION OF PAYMENT.
(M) "SECOND OPINION" MEANS AN OPPORTUNITY OR REQUIREMENT 1,215
TO OBTAIN A CLINICAL EVALUATION BY A PROVIDER OTHER THAN THE 1,216
PROVIDER ORIGINALLY MAKING A RECOMMENDATION FOR PROPOSED HEALTH 1,217
CARE SERVICES TO ASSESS THE CLINICAL NECESSITY AND 1,218
APPROPRIATENESS OF THE PROPOSED HEALTH CARE SERVICES. 1,219
(N) "UTILIZATION REVIEW" MEANS A PROCESS USED TO MONITOR 1,221
THE USE OF, OR EVALUATE THE CLINICAL NECESSITY, APPROPRIATENESS, 1,222
EFFICACY, OR EFFICIENCY OF, HEALTH CARE SERVICES, PROCEDURES, OR 1,223
SETTINGS. AREAS OF REVIEW MAY INCLUDE AMBULATORY REVIEW, 1,224
PROSPECTIVE REVIEW, SECOND OPINION, CERTIFICATION, CONCURRENT 1,225
REVIEW, CASE MANAGEMENT, DISCHARGE PLANNING, OR RETROSPECTIVE 1,226
REVIEW.
(O) "UTILIZATION REVIEW ORGANIZATION" MEANS AN ENTITY THAT 1,228
CONDUCTS UTILIZATION REVIEW, OTHER THAN A HEALTH INSURING 1,229
CORPORATION PERFORMING A REVIEW OF ITS OWN HEALTH CARE PLANS. 1,231
Sec. 1751.78. (A)(1) SECTIONS 1751.77 TO 1751.86 OF THE 1,234
REVISED CODE APPLY TO ANY HEALTH INSURING CORPORATION THAT 1,235
PROVIDES OR PERFORMS UTILIZATION REVIEW SERVICES IN CONNECTION 1,236
WITH ITS POLICIES, CONTRACTS, AND AGREEMENTS PROVIDING BASIC
HEALTH CARE SERVICES AND TO ANY DESIGNEE OF THE HEALTH INSURING 1,237
CORPORATION, OR TO ANY UTILIZATION REVIEW ORGANIZATION THAT 1,239
28
PERFORMS UTILIZATION REVIEW FUNCTIONS ON BEHALF OF THE HEALTH 1,240
INSURING CORPORATION IN CONNECTION WITH POLICIES, CONTRACTS, OR 1,241
AGREEMENTS OF THE HEALTH INSURING CORPORATION PROVIDING BASIC
HEALTH CARE SERVICES. 1,242
(2) NOTHING IN SECTIONS 1751.77 TO 1751.82 OR SECTION 1,244
1751.85 OF THE REVISED CODE SHALL BE CONSTRUED TO REQUIRE A 1,246
HEALTH INSURING CORPORATION TO PROVIDE OR PERFORM UTILIZATION 1,247
REVIEW SERVICES IN CONNECTION WITH HEALTH CARE SERVICES PROVIDED 1,248
UNDER A POLICY, PLAN, OR AGREEMENT OF SUPPLEMENTAL HEALTH CARE 1,249
SERVICES OR SPECIALTY HEALTH CARE SERVICES. 1,250
(B)(1) EACH HEALTH INSURING CORPORATION SHALL BE 1,253
RESPONSIBLE FOR MONITORING ALL UTILIZATION REVIEW ACTIVITIES 1,254
CARRIED OUT BY, OR ON BEHALF OF, THE HEALTH INSURING CORPORATION 1,255
AND FOR ENSURING THAT ALL REQUIREMENTS OF SECTIONS 1751.77 TO 1,256
1751.86 OF THE REVISED CODE, AND ANY RULES ADOPTED THEREUNDER, 1,258
ARE MET. THE HEALTH INSURING CORPORATION SHALL ALSO ENSURE THAT
APPROPRIATE PERSONNEL HAVE OPERATIONAL RESPONSIBILITY FOR THE 1,259
CONDUCT OF THE HEALTH INSURING CORPORATION'S UTILIZATION REVIEW 1,260
PROGRAM. 1,261
(2) IF A HEALTH INSURING CORPORATION CONTRACTS TO HAVE A 1,263
UTILIZATION REVIEW ORGANIZATION OR OTHER ENTITY PERFORM THE 1,264
UTILIZATION REVIEW FUNCTIONS REQUIRED BY SECTIONS 1751.77 TO 1,265
1751.86 OF THE REVISED CODE, AND ANY RULES ADOPTED THEREUNDER, 1,268
THE SUPERINTENDENT OF INSURANCE SHALL HOLD THE HEALTH INSURING 1,269
CORPORATION RESPONSIBLE FOR MONITORING THE ACTIVITIES OF THE
UTILIZATION REVIEW ORGANIZATION OR OTHER ENTITY AND FOR ENSURING 1,270
THAT THE REQUIREMENTS OF THOSE SECTIONS AND RULES ARE MET. 1,272
Sec. 1751.79. A HEALTH INSURING CORPORATION THAT CONDUCTS 1,274
UTILIZATION REVIEW SHALL PREPARE A WRITTEN UTILIZATION REVIEW 1,275
PROGRAM THAT DESCRIBES ALL REVIEW ACTIVITIES, BOTH DELEGATED AND 1,276
NONDELEGATED, FOR COVERED HEALTH CARE SERVICES PROVIDED, 1,278
INCLUDING THE FOLLOWING:
(A) PROCEDURES TO EVALUATE THE CLINICAL NECESSITY, 1,280
APPROPRIATENESS, EFFICACY, OR EFFICIENCY OF HEALTH CARE SERVICES; 1,282
29
(B) THE USE OF DATA SOURCES AND CLINICAL REVIEW CRITERIA 1,284
IN MAKING DECISIONS; 1,286
(C) MECHANISMS TO ENSURE CONSISTENT APPLICATION OF 1,288
CRITERIA AND COMPATIBLE DECISIONS; 1,289
(D) DATA COLLECTION PROCESSES AND ANALYTICAL METHODS USED 1,291
IN ASSESSING UTILIZATION OF HEALTH CARE SERVICES; 1,293
(E) MECHANISMS FOR ASSURING CONFIDENTIALITY OF CLINICAL 1,295
AND PROPRIETARY INFORMATION; 1,296
(F) THE PERIODIC ASSESSMENT OF UTILIZATION REVIEW 1,298
ACTIVITIES, AND THE REPORTING OF THESE ASSESSMENTS TO THE HEALTH 1,299
INSURING CORPORATION'S BOARD, BY A UTILIZATION REVIEW COMMITTEE, 1,300
A QUALITY ASSURANCE COMMITTEE, OR ANY SIMILAR COMMITTEE; 1,301
(G) THE FUNCTIONAL RESPONSIBILITY FOR DAY-TO-DAY PROGRAM 1,304
MANAGEMENT BY STAFF;
(H) DEFINED METHODS BY WHICH GUIDELINES ARE APPROVED AND 1,306
COMMUNICATED TO PROVIDERS AND HEALTH CARE FACILITIES. 1,307
Sec. 1751.80. THE UTILIZATION REVIEW PROGRAM OF A HEALTH 1,309
INSURING CORPORATION SHALL BE IMPLEMENTED IN ACCORDANCE WITH ALL 1,310
OF THE FOLLOWING: 1,311
(A) THE PROGRAM SHALL USE DOCUMENTED CLINICAL REVIEW 1,314
CRITERIA THAT ARE BASED ON SOUND CLINICAL EVIDENCE AND ARE 1,315
EVALUATED PERIODICALLY TO ASSURE ONGOING EFFICACY. A HEALTH 1,316
INSURING CORPORATION MAY DEVELOP ITS OWN CLINICAL REVIEW CRITERIA 1,317
OR MAY PURCHASE OR LICENSE SUCH CRITERIA FROM QUALIFIED VENDORS. 1,318
A HEALTH INSURING CORPORATION SHALL MAKE ITS CLINICAL REVIEW 1,319
RATIONALE AVAILABLE UPON REQUEST TO AUTHORIZED GOVERNMENT
AGENCIES. THE RATIONALE MADE AVAILABLE TO AUTHORIZED GOVERNMENT 1,320
AGENCIES IS CONFIDENTIAL AND IS NOT A PUBLIC RECORD AS DEFINED IN 1,322
SECTION 149.43 OF THE REVISED CODE. 1,324
(B) QUALIFIED PROVIDERS SHALL ADMINISTER THE PROGRAM AND 1,327
OVERSEE REVIEW DETERMINATIONS. A CLINICAL PEER IN THE SAME, OR 1,329
IN A SIMILAR, SPECIALTY AS TYPICALLY MANAGES THE MEDICAL
CONDITION, PROCEDURE, OR TREATMENT UNDER REVIEW SHALL EVALUATE 1,330
THE CLINICAL APPROPRIATENESS OF ADVERSE DETERMINATIONS THAT ARE 1,331
30
THE SUBJECT OF AN APPEAL. 1,332
(C) THE HEALTH INSURING CORPORATION SHALL ISSUE 1,335
UTILIZATION REVIEW DETERMINATIONS IN A TIMELY MANNER PURSUANT TO 1,336
THE REQUIREMENTS OF SECTIONS 1751.81 AND 1751.82 OF THE REVISED 1,338
CODE AND THE ENROLLEE GRIEVANCE REQUIREMENTS. THE HEALTH 1,339
INSURING CORPORATION SHALL OBTAIN INFORMATION REQUIRED TO MAKE A 1,341
UTILIZATION REVIEW DETERMINATION, INCLUDING PERTINENT CLINICAL
INFORMATION, AND SHALL ESTABLISH A PROCESS TO ENSURE THAT 1,342
UTILIZATION REVIEWERS APPLY CLINICAL REVIEW CRITERIA 1,343
CONSISTENTLY. 1,344
(D) IF THE HEALTH INSURING CORPORATION DELEGATES ANY 1,347
UTILIZATION REVIEW ACTIVITIES TO A UTILIZATION REVIEW 1,348
ORGANIZATION, THE HEALTH INSURING CORPORATION SHALL MAINTAIN 1,349
ADEQUATE OVERSIGHT, INCLUDING A PROCESS BY WHICH THE HEALTH 1,350
INSURING CORPORATION EVALUATES THE PERFORMANCE OF THE 1,351
ORGANIZATION, AND SHALL MAINTAIN COPIES OF BOTH OF THE FOLLOWING: 1,353
(1) A WRITTEN DESCRIPTION OF THE ORGANIZATION'S ACTIVITIES 1,356
AND RESPONSIBILITIES, INCLUDING REPORTING REQUIREMENTS; 1,357
(2) EVIDENCE OF FORMAL APPROVAL OF THE ORGANIZATION'S 1,359
PROGRAM BY THE HEALTH INSURING CORPORATION. 1,360
(E) THE HEALTH INSURING CORPORATION OR ITS DESIGNEE 1,363
UTILIZATION REVIEW ORGANIZATION SHALL PROVIDE ENROLLEES AND 1,364
PARTICIPATING PROVIDERS WITH ACCESS TO ITS REVIEW STAFF BY MEANS 1,365
OF A TOLL-FREE TELEPHONE NUMBER OR COLLECT-CALL TELEPHONE LINE. 1,366
(F) WHEN CONDUCTING PROSPECTIVE OR CONCURRENT REVIEW, THE 1,369
HEALTH INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,370
ORGANIZATION SHALL COLLECT ONLY THE INFORMATION NECESSARY TO 1,371
CERTIFY THE ADMISSION, PROCEDURE OR TREATMENT, LENGTH OF STAY, 1,372
FREQUENCY, AND DURATION OF HEALTH CARE SERVICES. 1,373
(G) COMPENSATION TO PERSONS PROVIDING UTILIZATION REVIEW 1,376
SERVICES FOR THE HEALTH INSURING CORPORATION SHALL NOT CONTAIN 1,377
INCENTIVES, DIRECT OR INDIRECT, FOR THEM TO MAKE INAPPROPRIATE 1,378
REVIEW DECISIONS.
Sec. 1751.81. (A) AS USED IN THIS SECTION: 1,380
31
(1) "ENROLLEE" INCLUDES THE REPRESENTATIVE OF AN ENROLLEE. 1,382
(2) "NECESSARY INFORMATION" INCLUDES THE RESULTS OF ANY 1,384
FACE-TO-FACE CLINICAL EVALUATION OR SECOND OPINION THAT MAY BE 1,386
REQUIRED.
(B) A HEALTH INSURING CORPORATION SHALL MAINTAIN WRITTEN 1,388
PROCEDURES FOR MAKING UTILIZATION REVIEW DETERMINATIONS AND FOR 1,390
NOTIFYING ENROLLEES, AND PARTICIPATING PROVIDERS AND HEALTH CARE 1,392
FACILITIES ACTING ON BEHALF OF ENROLLEES, OF ITS DETERMINATIONS. 1,393
(C) FOR INITIAL DETERMINATIONS, A HEALTH INSURING 1,395
CORPORATION SHALL MAKE THE DETERMINATION WITHIN TWO BUSINESS DAYS 1,397
AFTER OBTAINING ALL NECESSARY INFORMATION REGARDING A PROPOSED 1,399
ADMISSION, PROCEDURE, OR HEALTH CARE SERVICE REQUIRING A REVIEW 1,400
DETERMINATION. 1,401
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN 1,403
ADMISSION, PROCEDURE, OR HEALTH CARE SERVICE, THE HEALTH INSURING 1,404
CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE FACILITY 1,405
RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN THREE 1,406
BUSINESS DAYS AFTER MAKING THE INITIAL CERTIFICATION, AND SHALL 1,408
PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE
NOTIFICATION TO THE ENROLLEE AND THE PROVIDER OR HEALTH CARE 1,409
FACILITY WITHIN TWO BUSINESS DAYS AFTER MAKING THE TELEPHONE 1,411
NOTIFICATION.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,413
INSURING CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE 1,415
FACILITY RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN 1,416
THREE BUSINESS DAYS AFTER MAKING THE ADVERSE DETERMINATION, AND 1,417
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE 1,418
NOTIFICATION TO THE ENROLLEE AND THE PROVIDER OR HEALTH CARE 1,419
FACILITY WITHIN ONE BUSINESS DAY AFTER MAKING THE TELEPHONE 1,420
NOTIFICATION.
(D) FOR CONCURRENT REVIEW DETERMINATIONS, A HEALTH 1,422
INSURING CORPORATION SHALL MAKE THE DETERMINATION WITHIN ONE 1,424
BUSINESS DAY AFTER OBTAINING ALL NECESSARY INFORMATION. 1,425
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN EXTENDED 1,427
32
STAY OR ADDITIONAL HEALTH CARE SERVICES, THE HEALTH INSURING 1,428
CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE FACILITY 1,429
RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN ONE 1,430
BUSINESS DAY AFTER MAKING THE CERTIFICATION, AND SHALL PROVIDE 1,432
WRITTEN OR ELECTRONIC CONFIRMATION TO THE ENROLLEE AND THE
PROVIDER OR HEALTH CARE FACILITY WITHIN ONE BUSINESS DAY AFTER 1,433
THE TELEPHONE NOTIFICATION. THE WRITTEN NOTIFICATION SHALL 1,434
INCLUDE THE NUMBER OF EXTENDED DAYS OR NEXT REVIEW DATE, THE NEW 1,435
TOTAL NUMBER OF DAYS OF HEALTH CARE SERVICES APPROVED, AND THE 1,437
DATE OF ADMISSION OR INITIATION OF HEALTH CARE SERVICES.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,439
INSURING CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE 1,440
FACILITY RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN 1,441
ONE BUSINESS DAY AFTER MAKING THE ADVERSE DETERMINATION, AND 1,442
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION TO THE ENROLLEE 1,443
AND THE PROVIDER OR HEALTH CARE FACILITY WITHIN ONE BUSINESS DAY 1,444
AFTER THE TELEPHONE NOTIFICATION. THE HEALTH CARE SERVICE TO THE 1,445
ENROLLEE SHALL BE CONTINUED, WITH STANDARD COPAYMENTS AND 1,447
DEDUCTIBLES, IF APPLICABLE, UNTIL THE ENROLLEE HAS BEEN NOTIFIED 1,448
OF THE DETERMINATION. 1,449
(E) FOR RETROSPECTIVE REVIEW DETERMINATIONS, A HEALTH 1,451
INSURING CORPORATION SHALL MAKE THE DETERMINATION WITHIN THIRTY 1,454
BUSINESS DAYS AFTER RECEIVING ALL NECESSARY INFORMATION. 1,455
(1) IN THE CASE OF A CERTIFICATION, THE HEALTH INSURING 1,457
CORPORATION MAY NOTIFY THE ENROLLEE AND THE PROVIDER OR HEALTH 1,459
CARE FACILITY RENDERING THE HEALTH CARE SERVICE IN WRITING. 1,460
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,462
INSURING CORPORATION SHALL NOTIFY THE ENROLLEE AND THE PROVIDER 1,464
OR HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE, IN 1,465
WRITING, WITHIN FIVE BUSINESS DAYS AFTER MAKING THE ADVERSE 1,466
DETERMINATION.
(F) THE TIME FRAMES SET FORTH IN DIVISIONS (C), (D), AND 1,469
(E) OF THIS SECTION FOR DETERMINATIONS AND NOTIFICATIONS SHALL 1,470
PREVAIL UNLESS THE SERIOUSNESS OF THE MEDICAL CONDITION OF THE 1,471
33
ENROLLEE OTHERWISE REQUIRES A MORE TIMELY RESPONSE FROM THE
HEALTH INSURING CORPORATION. THE HEALTH INSURING CORPORATION 1,472
SHALL MAINTAIN WRITTEN PROCEDURES FOR MAKING EXPEDITED 1,474
UTILIZATION REVIEW DETERMINATIONS AND NOTIFICATIONS OF ENROLLEES 1,475
AND PROVIDERS OR HEALTH CARE FACILITIES WHEN WARRANTED BY THE 1,476
MEDICAL CONDITION OF THE ENROLLEE. 1,477
(G) A WRITTEN NOTIFICATION OF AN ADVERSE DETERMINATION 1,479
SHALL INCLUDE THE PRINCIPAL REASON OR REASONS FOR THE 1,480
DETERMINATION, INSTRUCTIONS FOR INITIATING AN APPEAL OR 1,481
RECONSIDERATION OF THE DETERMINATION, AND INSTRUCTIONS FOR 1,482
REQUESTING A WRITTEN STATEMENT OF THE CLINICAL RATIONALE USED TO 1,483
MAKE THE DETERMINATION. A HEALTH INSURING CORPORATION SHALL
PROVIDE THE CLINICAL RATIONALE FOR AN ADVERSE DETERMINATION IN 1,485
WRITING TO ANY PARTY WHO RECEIVED NOTICE OF THE ADVERSE 1,487
DETERMINATION AND WHO FOLLOWS THE INSTRUCTIONS FOR A REQUEST. 1,488
(H) A HEALTH INSURING CORPORATION SHALL HAVE WRITTEN 1,490
PROCEDURES TO ADDRESS THE FAILURE OR INABILITY OF A HEALTH CARE 1,493
FACILITY, PROVIDER, OR ENROLLEE TO PROVIDE ALL NECESSARY 1,495
INFORMATION FOR REVIEW. IF THE HEALTH CARE FACILITY, PROVIDER,
OR ENROLLEE WILL NOT RELEASE NECESSARY INFORMATION, THE HEALTH 1,497
INSURING CORPORATION MAY DENY CERTIFICATION. 1,498
Sec. 1751.82. (A) IN A CASE INVOLVING AN INITIAL 1,501
DETERMINATION OR A CONCURRENT REVIEW DETERMINATION, A HEALTH 1,502
INSURING CORPORATION SHALL GIVE THE PROVIDER OR HEALTH CARE 1,503
FACILITY RENDERING THE HEALTH CARE SERVICE AN OPPORTUNITY TO 1,504
REQUEST IN WRITING ON BEHALF OF THE ENROLLEE A RECONSIDERATION OF 1,505
AN ADVERSE DETERMINATION BY THE REVIEWER MAKING THE ADVERSE 1,506
DETERMINATION. THE RECONSIDERATION SHALL OCCUR WITHIN THREE 1,507
BUSINESS DAYS AFTER THE HEALTH INSURING CORPORATION'S RECEIPT OF 1,508
THE WRITTEN REQUEST FOR RECONSIDERATION, AND SHALL BE CONDUCTED 1,509
BETWEEN THE PROVIDER OR HEALTH CARE FACILITY RENDERING THE HEALTH 1,510
CARE SERVICE AND THE REVIEWER WHO MADE THE ADVERSE DETERMINATION. 1,512
IF THAT REVIEWER CANNOT BE AVAILABLE WITHIN THREE BUSINESS DAYS, 1,513
THE REVIEWER MAY DESIGNATE ANOTHER REVIEWER.
34
(B) IF THE RECONSIDERATION PROCESS DESCRIBED IN DIVISION 1,516
(A) OF THIS SECTION DOES NOT RESOLVE THE DIFFERENCE OF OPINION, 1,517
THE ADVERSE DETERMINATION MAY BE APPEALED BY THE ENROLLEE OR THE 1,518
PROVIDER OR HEALTH CARE FACILITY ON BEHALF OF THE ENROLLEE. 1,519
(C) RECONSIDERATION IS NOT A PREREQUISITE TO A STANDARD OR 1,521
EXPEDITED APPEAL OF AN ADVERSE DETERMINATION. 1,522
(D) THE TIME PERIOD ALLOWED BY DIVISION (A) OF THIS 1,525
SECTION FOR A RECONSIDERATION OF AN ADVERSE DETERMINATION SHALL 1,526
NOT APPLY IF THE SERIOUSNESS OF THE MEDICAL CONDITION OF THE 1,527
ENROLLEE REQUIRES A MORE EXPEDITED RECONSIDERATION. THE HEALTH 1,528
INSURING CORPORATION SHALL MAINTAIN WRITTEN PROCEDURES FOR MAKING 1,529
SUCH AN EXPEDITED RECONSIDERATION. 1,530
Sec. 1751.83. A HEALTH INSURING CORPORATION MAY PRESENT 1,533
EVIDENCE OF COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1751.77 1,534
TO 1751.82 OF THE REVISED CODE BY SUBMITTING EVIDENCE TO THE 1,535
SUPERINTENDENT OF INSURANCE OF ITS ACCREDITATION BY AN
INDEPENDENT, PRIVATE ACCREDITING ORGANIZATION, SUCH AS THE 1,536
NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION ON 1,537
ACCREDITATION OF HEALTH CARE ORGANIZATIONS, OR THE AMERICAN 1,538
ACCREDITATION HEALTHCARE COMMISSION/UTILIZATION REVIEW 1,539
ACCREDITATION COMMISSION. THE SUPERINTENDENT, UPON REVIEW OF THE 1,541
ORGANIZATION'S ACCREDITATION PROCESS, MAY DETERMINE THAT SUCH 1,542
ACCREDITATION CONSTITUTES COMPLIANCE BY THE HEALTH INSURING
CORPORATION WITH THE REQUIREMENTS OF THESE SECTIONS. 1,543
Sec. 1751.84. EACH PARTICIPATING PROVIDER OR HEALTH CARE 1,545
FACILITY SUBMITTING A CLAIM SHALL COOPERATE WITH THE UTILIZATION 1,547
REVIEW PROGRAM OF A HEALTH INSURING CORPORATION OR UTILIZATION
REVIEW ORGANIZATION AND SHALL PROVIDE THE HEALTH INSURING 1,548
CORPORATION OR ITS DESIGNEE ACCESS TO AN ENROLLEE'S MEDICAL 1,549
RECORDS DURING REGULAR BUSINESS HOURS, OR COPIES OF THOSE RECORDS 1,550
AT A REASONABLE COST. 1,551
Sec. 1751.85. A HEALTH INSURING CORPORATION SHALL ANNUALLY 1,553
FILE A CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE 1,554
CERTIFYING ITS COMPLIANCE WITH SECTIONS 1751.77 TO 1751.82 OF THE 1,555
35
REVISED CODE. 1,557
Sec. 1751.86. (A) NO HEALTH INSURING CORPORATION SHALL 1,560
FAIL TO COMPLY WITH SECTIONS 1751.77 TO 1751.82 OF THE REVISED 1,561
CODE.
(B) WHOEVER VIOLATES DIVISION (A) OF THIS SECTION IS 1,564
DEEMED TO HAVE ENGAGED IN AN UNFAIR AND DECEPTIVE ACT OR PRACTICE 1,566
IN THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 TO 3901.26 OF 1,567
THE REVISED CODE.
Sec. 1753.01. AS USED IN THIS CHAPTER: 1,569
(A) "ECONOMIC PROFILING" MEANS A HEALTH INSURING 1,571
CORPORATION'S USE OF ECONOMIC PERFORMANCE DATA AND ECONOMIC 1,572
INFORMATION IN DETERMINING WHETHER TO CONTRACT WITH A PROVIDER 1,573
FOR THE PROVISION OF COVERED HEALTH CARE SERVICES TO ENROLLEES AS 1,575
A PARTICIPATING PROVIDER.
(B) "BASIC HEALTH CARE SERVICES," "ENROLLEE," "HEALTH CARE 1,577
FACILITY," "HEALTH CARE SERVICES," "HEALTH INSURING CORPORATION," 1,578
"MEDICAL RECORD," "PROVIDER," AND "SUPPLEMENTAL HEALTH CARE 1,579
SERVICES" HAVE THE SAME MEANINGS AS IN SECTION 1751.01 OF THE 1,581
REVISED CODE.
Sec. 1753.03. THE SUPERINTENDENT OF INSURANCE SHALL 1,583
PRESCRIBE A STANDARD CREDENTIALING FORM TO BE USED BY ALL HEALTH 1,584
INSURING CORPORATIONS WHEN CREDENTIALING PROVIDERS IN CONNECTION 1,585
WITH POLICIES, CONTRACTS, AND AGREEMENTS PROVIDING BASIC HEALTH 1,586
CARE SERVICES. THE DIRECTOR OF HEALTH MAY MAKE RECOMMENDATIONS 1,587
TO THE SUPERINTENDENT FOR SUCH A STANDARD CREDENTIALING FORM. IF 1,588
THE DIRECTOR MAKES SUCH RECOMMENDATIONS, THE DIRECTOR SHALL TAKE 1,589
INTO CONSIDERATION THE STANDARD CREDENTIALING FORMS DEVELOPED BY 1,590
THE NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS, THE AMERICAN 1,592
MEDICAL ASSOCIATION, THE AMERICAN ASSOCIATION OF HEALTH PLANS, 1,594
AND ANY OTHER NATIONAL ORGANIZATION THAT HAS DEVELOPED SUCH A 1,595
FORM. IN PRESCRIBING A STANDARD CREDENTIALING FORM, THE 1,596
SUPERINTENDENT SHALL CONSIDER ANY RECOMMENDATIONS MADE BY THE 1,597
DIRECTOR. THE SUPERINTENDENT MAY AMEND OR REVISE THE PRESCRIBED 1,598
STANDARD CREDENTIALING FORM AS NECESSARY.
36
Sec. 1753.04. BEGINNING ONE HUNDRED TWENTY DAYS AFTER THE 1,600
SUPERINTENDENT OF INSURANCE PRESCRIBES A STANDARD CREDENTIALING 1,601
FORM UNDER SECTION 1753.03 OF THE REVISED CODE, NO HEALTH 1,604
INSURING CORPORATION SHALL FAIL TO USE THE PRESCRIBED STANDARD 1,605
CREDENTIALING FORM WHEN INITIALLY CREDENTIALING OR 1,606
RECREDENTIALING PROVIDERS IN CONNECTION WITH POLICIES, CONTRACTS, 1,607
AND AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES. IF THE 1,608
SUPERINTENDENT AMENDS OR REVISES THE STANDARD CREDENTIALING FORM, 1,610
A HEALTH INSURING CORPORATION SHALL USE THE AMENDED OR REVISED 1,611
FORM TO CREDENTIAL OR RECREDENTIAL PROVIDERS. 1,612
A HEALTH INSURING CORPORATION MAY REQUEST SUCH INFORMATION 1,615
FROM A PROVIDER, IN ADDITION TO THAT INFORMATION TO BE PROVIDED
ON THE STANDARD CREDENTIALING FORM, AS NECESSITATED BY THE HEALTH 1,617
INSURING CORPORATION'S CREDENTIALING STANDARDS.
Sec. 1753.05. (A) A HEALTH INSURING CORPORATION MAY USE 1,620
ECONOMIC PROFILING AS A FACTOR IN CREDENTIALING A PROVIDER, 1,621
HOWEVER, SUCH ECONOMIC PROFILING SHALL TAKE INTO CONSIDERATION 1,622
THE CASE MIX, SEVERITY OF ILLNESS, AND AGE OF PATIENTS. 1,623
(B) FOR AN INITIAL APPLICANT, A HEALTH INSURING 1,625
CORPORATION MAY REQUEST INFORMATION NECESSARY TO PERFORM AN 1,626
ECONOMIC PROFILE. IF INFORMATION ON CASE MIX, SEVERITY OF 1,627
ILLNESS, AND AGE OF PATIENTS IS REQUESTED BY A HEALTH INSURING 1,628
CORPORATION AND NOT PRODUCED BY THE APPLICANT, THE HEALTH 1,629
INSURING CORPORATION IS NOT REQUIRED TO TAKE THESE FACTORS INTO 1,630
CONSIDERATION IN ITS ECONOMIC PROFILE OF THE PROVIDER. 1,631
(C) NOTHING IN THIS SECTION PROHIBITS A HEALTH INSURING 1,634
CORPORATION FROM TAKING INTO CONSIDERATION THE QUALITY AND 1,635
APPROPRIATENESS OF CARE PROVIDED BY A PROVIDER WHEN DECIDING
WHETHER TO EMPLOY, CONTRACT WITH, OR TERMINATE THE PROVIDER. 1,637
Sec. 1753.06. A HEALTH INSURING CORPORATION SHALL NOTIFY A 1,640
PROVIDER SEEKING TO ENTER INTO A PARTICIPATION CONTRACT WITH THE
HEALTH INSURING CORPORATION OF THE STATUS OF THE PROVIDER'S 1,641
APPLICATION WITHIN ONE HUNDRED TWENTY DAYS AFTER THE HEALTH 1,642
INSURING CORPORATION'S RECEIPT OF THE PROVIDER'S COMPLETED 1,643
37
APPLICATION. THAT TIME PERIOD MAY BE EXTENDED BY A HEALTH 1,644
INSURING CORPORATION IF, DUE TO EXTENUATING CIRCUMSTANCES, THE 1,645
HEALTH INSURING CORPORATION NEEDS ADDITIONAL TIME TO CONSIDER THE 1,646
APPLICATION AND NOTIFIES THE PROVIDER OF THE REASON FOR THE 1,647
DELAY.
Sec. 1753.07. (A) PRIOR TO ENTERING INTO A PARTICIPATION 1,650
CONTRACT WITH A PROVIDER UNDER SECTION 1751.13 OF THE REVISED 1,651
CODE, A HEALTH INSURING CORPORATION SHALL DISCLOSE BASIC 1,652
INFORMATION REGARDING ITS PROGRAMS AND PROCEDURES TO THE 1,653
PROVIDER, UPON THE PROVIDER'S REQUEST. THE INFORMATION SHALL 1,654
INCLUDE ALL OF THE FOLLOWING:
(1) HOW A PARTICIPATING PROVIDER IS REIMBURSED FOR THE 1,656
PARTICIPATING PROVIDER'S SERVICES, INCLUDING THE RANGE AND 1,658
STRUCTURE OF ANY FINANCIAL RISK SHARING ARRANGEMENTS, A 1,659
DESCRIPTION OF ANY INCENTIVE PLANS, AND, IF REIMBURSED ACCORDING 1,660
TO A TYPE OF FEE-FOR-SERVICE ARRANGEMENT, THE LEVEL OF 1,661
REIMBURSEMENT FOR THE PARTICIPATING PROVIDER'S SERVICES; 1,662
(2) HOW REFERRALS TO OTHER PARTICIPATING PROVIDERS OR TO 1,664
NONPARTICIPATING PROVIDERS ARE MADE; 1,665
(3) THE AVAILABILITY OF DISPUTE RESOLUTION PROCEDURES AND 1,667
THE POTENTIAL FOR COST TO BE INCURRED; 1,668
(4) HOW A PARTICIPATING PROVIDER'S NAME AND ADDRESS WILL 1,670
BE USED IN MARKETING MATERIALS. 1,671
(B) A HEALTH INSURING CORPORATION SHALL PROVIDE ALL OF THE 1,674
FOLLOWING TO A PARTICIPATING PROVIDER:
(1) ANY MATERIAL INCORPORATED BY REFERENCE INTO THE 1,676
PARTICIPATION CONTRACT, THAT IS NOT OTHERWISE AVAILABLE AS A 1,677
PUBLIC RECORD, IF SUCH MATERIAL AFFECTS THE PARTICIPATING 1,678
PROVIDER;
(2) ADMINISTRATIVE MANUALS RELATED TO PROVIDER 1,680
PARTICIPATION, IF ANY; 1,681
(3) A SIGNED AND DATED COPY OF THE FINAL PARTICIPATION 1,683
CONTRACT. 1,684
Sec. 1753.08. (A) A HEALTH INSURING CORPORATION SHALL 1,686
38
NOTIFY A PARTICIPATING PROVIDER PRIOR TO THE EFFECTIVE DATE OF AN 1,688
AMENDMENT TO THE PARTICIPATING PROVIDER'S CONTRACT WITH THE 1,690
HEALTH INSURING CORPORATION, AND PRIOR TO THE EFFECTIVE DATE OF
AN AMENDMENT TO ANY DOCUMENT INCORPORATED BY REFERENCE INTO THE 1,692
CONTRACT IF THE AMENDMENT OF THE DOCUMENT DIRECTLY AND MATERIALLY 1,693
AFFECTS THE PARTICIPATING PROVIDER. SUCH AMENDMENTS SHALL NOT BE 1,695
EFFECTIVE WITH REGARD TO A PARTICIPATING PROVIDER UNTIL THE 1,696
PARTICIPATING PROVIDER HAS HAD REASONABLE TIME, AS DEFINED IN THE 1,697
CONTRACT, TO EXERCISE THE PARTICIPATING PROVIDER'S RIGHT TO 1,698
TERMINATE ITS PARTICIPATION STATUS IN ACCORDANCE WITH THE TERMS 1,699
AND CONDITIONS OF THE CONTRACT. 1,700
(B) DIVISION (A) OF THIS SECTION DOES NOT APPLY IF THE 1,703
DELAY CAUSED BY COMPLIANCE WITH THAT DIVISION COULD RESULT IN 1,704
IMMINENT HARM TO AN ENROLLEE OR IF THE AMENDMENT IS REQUIRED BY 1,705
STATE OR FEDERAL LAW, RULE, OR REGULATION. 1,706
Sec. 1753.09. (A) EXCEPT AS PROVIDED IN DIVISION (D) OF 1,709
THIS SECTION, PRIOR TO TERMINATING THE PARTICIPATION OF A 1,710
PROVIDER ON THE BASIS OF THE PARTICIPATING PROVIDER'S FAILURE TO 1,711
MEET THE HEALTH INSURING CORPORATION'S STANDARDS FOR QUALITY OR 1,712
UTILIZATION IN THE DELIVERY OF HEALTH CARE SERVICES, A HEALTH 1,714
INSURING CORPORATION SHALL GIVE THE PARTICIPATING PROVIDER NOTICE 1,715
OF THE REASON OR REASONS FOR ITS DECISION TO TERMINATE THE 1,716
PROVIDER'S PARTICIPATION AND AN OPPORTUNITY TO TAKE CORRECTIVE 1,717
ACTION. THE HEALTH INSURING CORPORATION SHALL DEVELOP A 1,718
PERFORMANCE IMPROVEMENT PLAN IN CONJUNCTION WITH THE
PARTICIPATING PROVIDER. IF AFTER BEING AFFORDED THE OPPORTUNITY 1,719
TO COMPLY WITH THE PERFORMANCE IMPROVEMENT PLAN, THE 1,720
PARTICIPATING PROVIDER FAILS TO DO SO, THE HEALTH INSURING 1,721
CORPORATION MAY TERMINATE THE PARTICIPATION OF THE PROVIDER. 1,722
(B)(1) A PARTICIPATING PROVIDER WHOSE PARTICIPATION HAS 1,724
BEEN TERMINATED UNDER DIVISION (A) OF THIS SECTION MAY APPEAL THE 1,727
TERMINATION TO THE APPROPRIATE MEDICAL DIRECTOR OF THE HEALTH 1,728
INSURING CORPORATION. THE MEDICAL DIRECTOR SHALL GIVE THE 1,729
PARTICIPATING PROVIDER AN OPPORTUNITY TO DISCUSS WITH THE MEDICAL 1,730
39
DIRECTOR THE REASON OR REASONS FOR THE TERMINATION.
(2) IF A SATISFACTORY RESOLUTION OF A PARTICIPATING 1,732
PROVIDER'S APPEAL CANNOT BE REACHED UNDER DIVISION (B)(1) OF THIS 1,734
SECTION, THE PARTICIPATING PROVIDER MAY APPEAL THE TERMINATION TO 1,735
A PANEL COMPOSED OF PARTICIPATING PROVIDERS WHO HAVE COMPARABLE 1,737
OR HIGHER LEVELS OF EDUCATION AND TRAINING THAN THE PARTICIPATING 1,738
PROVIDER MAKING THE APPEAL. A REPRESENTATIVE OF THE 1,739
PARTICIPATING PROVIDER'S SPECIALTY SHALL BE A MEMBER OF THE 1,740
PANEL, IF POSSIBLE. THIS PANEL SHALL HOLD A HEARING, AND SHALL 1,741
RENDER ITS RECOMMENDATION IN THE APPEAL WITHIN THIRTY DAYS AFTER 1,742
HOLDING THE HEARING. THE RECOMMENDATION SHALL BE PRESENTED TO 1,743
THE MEDICAL DIRECTOR AND TO THE PARTICIPATING PROVIDER. 1,744
(3) THE MEDICAL DIRECTOR SHALL REVIEW AND CONSIDER THE 1,746
PANEL'S RECOMMENDATION BEFORE MAKING A DECISION. THE DECISION 1,747
RENDERED BY THE MEDICAL DIRECTOR SHALL BE FINAL. 1,748
(C) A PROVIDER'S STATUS AS A PARTICIPATING PROVIDER SHALL 1,751
REMAIN IN EFFECT DURING THE APPEAL PROCESS SET FORTH IN DIVISION 1,753
(B) OF THIS SECTION UNLESS THE TERMINATION WAS BASED ON ANY OF 1,754
THE REASONS LISTED IN DIVISION (D) OF THIS SECTION. 1,756
(D) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A 1,758
PROVIDER'S PARTICIPATION MAY BE IMMEDIATELY TERMINATED IF THE 1,760
PARTICIPATING PROVIDER'S CONDUCT PRESENTS AN IMMINENT RISK OF 1,761
HARM TO AN ENROLLEE OR ENROLLEES; OR IF THERE HAS OCCURRED 1,762
UNACCEPTABLE QUALITY OF CARE, FRAUD, PATIENT ABUSE, LOSS OF 1,763
CLINICAL PRIVILEGES, LOSS OF PROFESSIONAL LIABILITY COVERAGE, 1,764
INCOMPETENCE, OR LOSS OF AUTHORITY TO PRACTICE IN THE 1,765
PARTICIPATING PROVIDER'S FIELD; OR IF A GOVERNMENTAL ACTION HAS 1,766
IMPAIRED THE PARTICIPATING PROVIDER'S ABILITY TO PRACTICE. 1,767
(E) DIVISIONS (A) TO (D) OF THIS SECTION APPLY ONLY TO 1,770
PROVIDERS WHO ARE NATURAL PERSONS.
(F)(1) NOTHING IN THIS SECTION PROHIBITS A HEALTH INSURING 1,773
CORPORATION FROM REJECTING A PROVIDER'S APPLICATION FOR 1,774
PARTICIPATION, OR FROM TERMINATING A PARTICIPATING PROVIDER'S 1,775
CONTRACT, IF THE HEALTH INSURING CORPORATION DETERMINES THAT THE 1,776
40
HEALTH CARE NEEDS OF ITS ENROLLEES ARE BEING MET AND NO NEED 1,777
EXISTS FOR THE PROVIDER'S OR PARTICIPATING PROVIDER'S SERVICES. 1,778
(2) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS 1,780
PROHIBITING A HEALTH INSURING CORPORATION FROM TERMINATING A 1,781
PARTICIPATING PROVIDER WHO DOES NOT MEET THE TERMS AND CONDITIONS 1,783
OF THE PARTICIPATING PROVIDER'S CONTRACT.
(G) THE SUPERINTENDENT OF INSURANCE MAY ADOPT RULES AS 1,786
NECESSARY TO IMPLEMENT AND ENFORCE SECTIONS 1753.04 TO 1753.09 OF 1,787
THE REVISED CODE. SUCH RULES SHALL BE ADOPTED IN ACCORDANCE WITH 1,789
CHAPTER 119. OF THE REVISED CODE. THE DIRECTOR OF HEALTH MAY 1,793
MAKE RECOMMENDATIONS TO THE SUPERINTENDENT FOR RULES NECESSARY TO 1,794
IMPLEMENT AND ENFORCE SECTIONS 1753.04 TO 1753.09 OF THE REVISED 1,795
CODE. IN ADOPTING ANY RULES PURSUANT TO THIS DIVISION, THE 1,797
SUPERINTENDENT SHALL CONSIDER THE RECOMMENDATIONS OF THE 1,798
DIRECTOR.
Sec. 1753.10. NOTHING IN THIS CHAPTER OR CHAPTER 1751. OF 1,801
THE REVISED CODE REQUIRES A HEALTH INSURING CORPORATION TO EMPLOY 1,804
OR CONTRACT WITH, OR PROHIBITS A HEALTH INSURING CORPORATION FROM 1,805
EMPLOYING OR CONTRACTING WITH, ANY CATEGORY OF PROVIDER FOR THE 1,806
PROVISION OF BASIC OR SUPPLEMENTAL HEALTH CARE SERVICES, WHICH 1,807
HEALTH CARE SERVICES ARE WITHIN THE RECOGNIZED SCOPE OF PRACTICE 1,808
OF THAT CATEGORY OF PROVIDER. 1,809
Sec. 1753.14. (A) A HEALTH INSURING CORPORATION THAT DOES 1,812
NOT ALLOW DIRECT ACCESS TO ALL SPECIALISTS SHALL ESTABLISH AND 1,813
IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE MAY RECEIVE A STANDING 1,814
REFERRAL TO A SPECIALIST. THE PROCEDURE SHALL PROVIDE FOR A 1,815
STANDING REFERRAL TO A SPECIALIST IF A PRIMARY CARE PROVIDER 1,816
DETERMINES IN CONSULTATION WITH A SPECIALIST THAT AN ENROLLEE 1,817
NEEDS CONTINUING CARE FROM A SPECIALIST. THE REFERRAL SHALL BE 1,818
MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE HEALTH INSURING 1,819
CORPORATION IN CONSULTATION WITH THE PRIMARY CARE PROVIDER, A 1,820
SPECIALIST, AND THE ENROLLEE. THE TREATMENT PLAN MAY LIMIT THE 1,821
NUMBER OF VISITS TO THE SPECIALIST, LIMIT THE PERIOD OF TIME THAT 1,822
THE VISITS ARE AUTHORIZED, OR REQUIRE THAT THE SPECIALIST PROVIDE 1,823
41
THE PRIMARY CARE PROVIDER WITH REGULAR REPORTS ON THE HEALTH CARE 1,825
PROVIDED TO THE ENROLLEE.
(B) A HEALTH INSURING CORPORATION SHALL ESTABLISH AND 1,828
IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE WITH A CONDITION OR 1,829
DISEASE THAT REQUIRES SPECIALIZED MEDICAL CARE OVER A PROLONGED 1,830
PERIOD OF TIME AND IS LIFE-THREATENING, DEGENERATIVE, OR 1,831
DISABLING MAY RECEIVE A REFERRAL TO A SPECIALIST WHO HAS 1,832
EXPERTISE IN TREATING THE CONDITION OR DISEASE FOR THE PURPOSE OF 1,833
HAVING THE SPECIALIST COORDINATE THE ENROLLEE'S HEALTH CARE. THE 1,835
PROCEDURE SHALL PROVIDE FOR SUCH A REFERRAL IF A PRIMARY CARE 1,836
PROVIDER DETERMINES IN CONSULTATION WITH THE SPECIALIST THAT THE 1,837
ENROLLEE NEEDS THE SPECIALIST'S EXPERTISE. THE REFERRAL SHALL BE 1,839
MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE HEALTH INSURING 1,841
CORPORATION IN CONSULTATION WITH THE PRIMARY CARE PROVIDER, THE 1,842
SPECIALIST, AND THE ENROLLEE. AFTER THE REFERRAL IS MADE, THE 1,843
SPECIALIST IS AUTHORIZED TO PROVIDE HEALTH CARE SERVICES TO THE 1,844
ENROLLEE IN THE SAME MANNER AS THE ENROLLEE'S PRIMARY CARE 1,845
PROVIDER, SUBJECT TO THE TERMS OF THE TREATMENT PLAN. 1,846
(C) THE DETERMINATIONS DESCRIBED IN DIVISIONS (A) AND (B) 1,850
OF THIS SECTION SHALL BE MADE WITHIN THREE BUSINESS DAYS AFTER A 1,851
REQUEST FOR THE DETERMINATION IS MADE BY THE ENROLLEE OR THE 1,852
ENROLLEE'S PRIMARY CARE PROVIDER AND ALL APPROPRIATE MEDICAL 1,853
RECORDS AND OTHER ITEMS OF INFORMATION NECESSARY TO MAKE THE 1,854
DETERMINATION HAVE BEEN PROVIDED. 1,855
(D) ONCE A DETERMINATION IN FAVOR OF A REFERRAL IS MADE, 1,857
THE REFERRAL SHALL BE MADE WITHIN FOUR BUSINESS DAYS AFTER THE 1,859
DETERMINATION. THIS TIME PERIOD DOES NOT APPLY TO STANDING 1,860
REFERRALS INVOLVING A RARE OR UNUSUAL CONDITION FOR WHICH 1,861
APPROPRIATE SPECIALISTS ARE LIMITED IN NUMBER OR OTHERWISE 1,862
DIFFICULT TO IDENTIFY. 1,863
DIVISIONS (A) AND (B) OF THIS SECTION DO NOT REQUIRE A 1,867
HEALTH INSURING CORPORATION TO PERMIT AN ENROLLEE TO ELECT 1,868
REFERRAL TO A SPECIALIST WHO IS NOT EMPLOYED BY OR UNDER CONTRACT 1,869
WITH THE HEALTH INSURING CORPORATION FOR THE PROVISION OF HEALTH 1,870
42
CARE SERVICES TO THE HEALTH INSURING CORPORATION'S ENROLLEES. 1,871
Sec. 1753.16. A HEALTH INSURING CORPORATION OR UTILIZATION 1,874
REVIEW ORGANIZATION THAT AUTHORIZES A PROPOSED ADMISSION, 1,875
TREATMENT, OR HEALTH CARE SERVICE BY A PARTICIPATING PROVIDER
BASED UPON THE COMPLETE AND ACCURATE SUBMISSION OF ALL NECESSARY 1,876
INFORMATION RELATIVE TO AN ELIGIBLE ENROLLEE SHALL NOT 1,877
RETROACTIVELY DENY THIS AUTHORIZATION IF THE PROVIDER RENDERS THE 1,878
HEALTH CARE SERVICE IN GOOD FAITH AND PURSUANT TO THE 1,879
AUTHORIZATION AND ALL OF THE TERMS AND CONDITIONS OF THE 1,880
PROVIDER'S CONTRACT WITH THE HEALTH INSURING CORPORATION. 1,881
Sec. 1753.21. (A) IF A POLICY, CONTRACT, OR AGREEMENT OF 1,883
A HEALTH INSURING CORPORATION USES A RESTRICTED FORMULARY OF 1,886
PRESCRIPTION DRUGS, THE HEALTH INSURING CORPORATION SHALL DO BOTH 1,887
OF THE FOLLOWING:
(1) DEVELOP SUCH A FORMULARY IN CONSULTATION WITH AND WITH 1,890
THE APPROVAL OF A PHARMACY AND THERAPEUTICS COMMITTEE, A MAJORITY 1,891
OF THE MEMBERS OF WHICH ARE PHYSICIANS AFFILIATED WITH THE HEALTH 1,892
INSURING CORPORATION WHO MAY PRESCRIBE PRESCRIPTION DRUGS AND 1,893
PHARMACISTS AFFILIATED WITH THE HEALTH INSURING CORPORATION; OR 1,894
IN CONSULTATION WITH AND WITH THE APPROVAL OF A PHARMACY AND 1,895
THERAPEUTICS COMMITTEE THAT IS INDEPENDENT OF THE HEALTH INSURING 1,896
CORPORATION CONSISTING OF PHYSICIANS WHO MAY PRESCRIBE 1,897
PRESCRIPTION DRUGS IN THEIR STATE OF LICENSURE AND PHARMACISTS 1,898
WHO ARE AUTHORIZED TO PRACTICE IN THEIR STATE OF LICENSURE; 1,900
(2) ESTABLISH A PROCEDURE BY WHICH AN ENROLLEE MAY OBTAIN, 1,903
WITHOUT PENALTY OR ADDITIONAL COST SHARING BEYOND THAT PROVIDED 1,904
FOR FORMULARY DRUGS UNDER THE ENROLLEE'S CONTRACT WITH THE HEALTH 1,905
INSURING CORPORATION, COVERAGE OF A SPECIFIC NONFORMULARY DRUG 1,906
WHEN THE PRESCRIBER DOCUMENTS IN THE ENROLLEE'S MEDICAL RECORD 1,907
AND CERTIFIES THAT THE FORMULARY ALTERNATIVE HAS BEEN INEFFECTIVE 1,908
IN THE TREATMENT OF THE ENROLLEE'S DISEASE OR CONDITION, OR THAT 1,909
THE FORMULARY ALTERNATIVE CAUSES OR IS REASONABLY EXPECTED BY THE 1,910
PRESCRIBER TO CAUSE A HARMFUL OR ADVERSE REACTION IN THE 1,911
ENROLLEE.
43
(B) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE 1,914
A HEALTH INSURING CORPORATION TO PLACE ANY PARTICULAR 1,915
PHARMACEUTICAL PRODUCT OR THERAPEUTIC CLASS OF PRODUCT ON ANY 1,916
FORMULARY, OR TO PROHIBIT A HEALTH INSURING CORPORATION FROM 1,917
RESTRICTING PAYMENTS FOR ANY SPECIFIC PHARMACEUTICAL PRODUCT OR 1,918
THERAPEUTIC CLASS OF PRODUCT, INCLUDING, BUT NOT LIMITED TO, A 1,919
REQUIREMENT THAT THE PRODUCT BE PRESCRIBED ONLY BY A DEFINED 1,920
SPECIALIST OR SUBSPECIALIST.
Sec. 1753.23. A HEALTH INSURING CORPORATION SHALL 1,923
ESTABLISH OR USE AN INTERNAL TECHNOLOGY ASSESSMENT PROCESS FOR
ASSESSING WHETHER A DRUG, DEVICE, PROTOCOL, PROCEDURE, OR OTHER 1,924
THERAPY IS PROVEN TO BE SAFE AND EFFICACIOUS FOR A PARTICULAR 1,925
INDICATION OR CONDITION WHEN COMPARED TO ALTERNATIVE THERAPIES, 1,926
OR WHETHER IT REMAINS EXPERIMENTAL OR INVESTIGATIONAL. THE 1,927
HEALTH INSURING CORPORATION'S INTERNAL TECHNOLOGY ASSESSMENT 1,928
PROCESS SHALL MEET ALL OF THE FOLLOWING CRITERIA: 1,929
(A) DECISIONS ARE MADE BY MEDICAL PROFESSIONALS, INCLUDING 1,932
PHYSICIANS.
(B) THE PROCESS INCLUDES A REVIEW OF RELEVANT MEDICAL 1,935
EVIDENCE, INCLUDING THE FOLLOWING, IF AVAILABLE: 1,936
(1) PEER-REVIEWED MEDICAL AND SCIENTIFIC LITERATURE ON THE 1,939
SUBJECT;
(2) PUBLISHED OPINIONS, ACTIONS, AND OTHER RELEVANT 1,941
DOCUMENTS OF INDEPENDENT, EXTERNAL RESEARCH ORGANIZATIONS SUCH AS 1,943
THE NATIONAL INSTITUTE OF HEALTH, THE NATIONAL CANCER INSTITUTE, 1,944
THE UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 1,946
FINANCE ADMINISTRATION, AND THE AGENCY FOR HEALTH CARE POLICY AND 1,947
RESEARCH; 1,948
(3) PUBLISHED OPINIONS OF MEDICAL EXPERTS OR AFFECTED 1,950
SPECIALTY SOCIETIES. 1,951
(C) GENERAL COVERAGE DECISIONS, MADE PURSUANT TO THIS 1,954
PROCESS, THAT EXCLUDE DRUGS, DEVICES, PROTOCOLS, PROCEDURES, OR 1,955
OTHER THERAPIES ON THE BASIS THAT THEY ARE NOT SAFE OR 1,956
EFFICACIOUS AND REMAIN EXPERIMENTAL OR INVESTIGATIONAL, ARE 1,957
44
REVIEWED AND UPDATED AS NEW SCIENTIFIC EVIDENCE BECOMES 1,958
AVAILABLE.
(D) A DESCRIPTION OF THE HEALTH INSURING CORPORATION'S 1,961
INTERNAL TECHNOLOGY ASSESSMENT PROCESS IS MADE AVAILABLE TO 1,962
PARTICIPATING PROVIDERS AND ENROLLEES, UPON REQUEST. 1,963
(E) A COPY OF THE HEALTH INSURING CORPORATION'S SPECIFIC 1,966
COVERAGE PROTOCOLS AND PROCEDURES IS MADE AVAILABLE TO 1,967
PARTICIPATING PROVIDERS AND ENROLLEES UPON THE REQUEST OF AN 1,968
ENROLLEE WHO HAS BEEN DENIED COVERAGE FOR A DRUG, DEVICE, 1,969
PROTOCOL, PROCEDURE, OR OTHER THERAPY ON THE BASIS THAT IT HAS 1,970
BEEN ASSESSED AS NOT BEING SAFE OR EFFICACIOUS FOR A PARTICULAR 1,971
INDICATION OR CONDITION. SPECIFIC COVERAGE PROTOCOLS AND 1,972
PROCEDURES SHALL INCLUDE A DESCRIPTION OF THE EVIDENCE UPON WHICH 1,973
THE PROTOCOL OR PROCEDURE IS BASED, AND SHALL CONTAIN THE DATE 1,974
THE PROTOCOL OR PROCEDURE WAS ADOPTED. 1,975
Sec. 1753.24. (A) EACH HEALTH INSURING CORPORATION SHALL 1,977
ESTABLISH A REASONABLE EXTERNAL, INDEPENDENT REVIEW PROCESS TO 1,979
EXAMINE THE HEALTH INSURING CORPORATION'S COVERAGE DECISIONS FOR 1,981
ENROLLEES WHO MEET ALL OF THE FOLLOWING CRITERIA:
(1) THE ENROLLEE HAS A TERMINAL CONDITION THAT, ACCORDING 1,983
TO THE CURRENT DIAGNOSIS OF THE ENROLLEE'S PHYSICIAN, HAS A HIGH 1,984
PROBABILITY OF CAUSING DEATH WITHIN TWO YEARS. 1,985
(2) THE ENROLLEE'S PHYSICIAN CERTIFIES THAT THE ENROLLEE 1,987
HAS THE CONDITION DESCRIBED IN DIVISION (A)(1) OF THIS SECTION 1,988
AND ANY OF THE FOLLOWING SITUATIONS ARE APPLICABLE: 1,989
(a) STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN 1,991
IMPROVING THE CONDITION OF THE ENROLLEE; 1,993
(b) STANDARD THERAPIES ARE NOT MEDICALLY APPROPRIATE FOR 1,996
THE ENROLLEE;
(c) THERE IS NO STANDARD THERAPY COVERED BY THE HEALTH 1,999
INSURING CORPORATION THAT IS MORE BENEFICIAL THAN THERAPY 2,000
DESCRIBED IN DIVISION (A)(3) OF THIS SECTION. 2,001
(3) THE ENROLLEE'S PHYSICIAN HAS RECOMMENDED A DRUG, 2,003
DEVICE, PROCEDURE, OR OTHER THERAPY THAT THE PHYSICIAN CERTIFIES, 2,004
45
IN WRITING, IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE, IN 2,005
THE PHYSICIAN'S OPINION, THAN STANDARD THERAPIES, OR, THE 2,007
ENROLLEE HAS REQUESTED A THERAPY THAT HAS BEEN FOUND IN A
PREPONDERANCE OF PEER-REVIEWED PUBLISHED STUDIES TO BE ASSOCIATED 2,008
WITH EFFECTIVE CLINICAL OUTCOMES FOR THE SAME CONDITION. 2,009
(4) THE ENROLLEE HAS BEEN DENIED COVERAGE BY THE HEALTH 2,011
INSURING CORPORATION FOR A DRUG, DEVICE, PROCEDURE, OR OTHER 2,014
THERAPY RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF 2,015
THIS SECTION, AND HAS EXHAUSTED ALL INTERNAL APPEALS.
(5) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, 2,017
RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF THIS 2,019
SECTION, WOULD BE A COVERED HEALTH CARE SERVICE EXCEPT FOR THE 2,021
HEALTH INSURING CORPORATION'S DETERMINATION THAT THE DRUG,
DEVICE, PROCEDURE, OR OTHER THERAPY IS EXPERIMENTAL OR 2,023
INVESTIGATIONAL.
(B) THE EXTERNAL, INDEPENDENT REVIEW PROCESS ESTABLISHED 2,025
BY A HEALTH INSURING CORPORATION SHALL MEET ALL OF THE FOLLOWING 2,026
CRITERIA:
(1) EXCEPT AS PROVIDED IN DIVISION (C) OF THIS SECTION, 2,028
THE PROCESS SHALL OFFER ALL ENROLLEES WHO MEET THE CRITERIA SET 2,029
FORTH IN DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE THE 2,031
HEALTH INSURING CORPORATION'S DECISION TO DENY COVERAGE OF THE 2,032
RECOMMENDED OR REQUESTED THERAPY REVIEWED UNDER THE PROCESS. 2,033
EACH ELIGIBLE ENROLLEE SHALL BE NOTIFIED OF THAT OPPORTUNITY 2,034
WITHIN FIVE BUSINESS DAYS AFTER THE HEALTH INSURING CORPORATION 2,035
DENIES COVERAGE.
(2) THE REVIEW OF THE HEALTH INSURING CORPORATION'S 2,037
DECISION SHALL BE CONDUCTED BY EXPERTS SELECTED BY AN INDEPENDENT 2,038
ENTITY THAT HAS BEEN RETAINED BY THE HEALTH INSURING CORPORATION 2,039
FOR THIS PURPOSE. THE INDEPENDENT ENTITY SHALL BE EITHER AN 2,040
ACADEMIC MEDICAL CENTER OR AN ENTITY THAT HAS AS ITS PRIMARY 2,041
FUNCTION, AND THAT RECEIVES A MAJORITY OF ITS REVENUE FROM, THE 2,042
PROVISION OF EXPERT REVIEWS AND RELATED SERVICES. 2,043
THE INDEPENDENT ENTITY SHALL SELECT A PANEL TO CONDUCT THE 2,046
46
REVIEW, WHICH PANEL SHALL BE COMPOSED OF AT LEAST THREE 2,047
PHYSICIANS OR OTHER PROVIDERS WHO ARE EXPERTS IN THE TREATMENT OF 2,048
THE ENROLLEE'S MEDICAL CONDITION AND KNOWLEDGEABLE ABOUT THE 2,049
RECOMMENDED OR REQUESTED THERAPY. IF THE INDEPENDENT ENTITY 2,050
RETAINED BY THE HEALTH INSURING CORPORATION IS AN ACADEMIC 2,052
MEDICAL CENTER, THE PANEL MAY INCLUDE EXPERTS AFFILIATED WITH OR 2,053
EMPLOYED BY THE ACADEMIC MEDICAL CENTER. 2,054
IN EITHER OF THE FOLLOWING CIRCUMSTANCES, AN EXCEPTION MAY 2,057
BE MADE TO THE REQUIREMENT THAT THE REVIEW BE CONDUCTED BY AN 2,058
EXPERT PANEL COMPOSED OF A MINIMUM OF THREE PHYSICIANS OR OTHER 2,059
PROVIDERS:
(a) A REVIEW MAY BE CONDUCTED BY AN EXPERT PANEL COMPOSED 2,062
OF ONLY TWO PHYSICIANS OR OTHER PROVIDERS IF AN ENROLLEE HAS 2,063
CONSENTED IN WRITING TO A REVIEW BY THE SMALLER PANEL; 2,064
(b) A REVIEW MAY BE CONDUCTED BY A SINGLE EXPERT PHYSICIAN 2,067
OR OTHER PROVIDER IF ONLY ONE EXPERT PHYSICIAN OR OTHER PROVIDER 2,068
IS AVAILABLE FOR THE REVIEW.
(3) NEITHER THE HEALTH INSURING CORPORATION NOR THE 2,070
ENROLLEE SHALL CHOOSE, OR CONTROL THE CHOICE OF, THE PHYSICIAN OR 2,072
OTHER PROVIDER EXPERTS.
(4) NEITHER THE EXPERTS NOR THE INDEPENDENT ENTITY 2,074
ARRANGING FOR THE EXPERTS' REVIEW SHALL HAVE ANY PROFESSIONAL, 2,075
FAMILIAL, OR FINANCIAL AFFILIATION WITH THE HEALTH INSURING 2,077
CORPORATION, EXCEPT THAT EXPERTS AFFILIATED WITH ACADEMIC MEDICAL 2,078
CENTERS WHO PROVIDE HEALTHCARE SERVICES TO ENROLLEES OF THE 2,079
HEALTH INSURING CORPORATION MAY SERVE AS EXPERTS ON THE REVIEW 2,080
PANEL. THIS NONAFFILIATION PROVISION DOES NOT PRECLUDE A HEALTH 2,082
INSURING CORPORATION FROM PAYING FOR THE EXPERTS' REVIEW, AS
SPECIFIED IN DIVISION (B)(5) OF THIS SECTION. THE EXPERTS SHALL 2,084
HAVE NO PATIENT-PHYSICIAN RELATIONSHIP OR OTHER AFFILIATION WITH 2,085
AN ENROLLEE WHOSE REQUEST FOR THERAPY IS UNDER REVIEW OR WITH A 2,086
PROVIDER WHOSE RECOMMENDATION FOR THERAPY IS UNDER REVIEW. 2,087
(5) ENROLLEES SHALL NOT BE REQUIRED TO PAY FOR THE 2,089
EXTERNAL, INDEPENDENT REVIEW. THE COSTS OF THE REVIEW SHALL BE 2,090
47
BORNE BY THE HEALTH INSURING CORPORATION. 2,091
(6) THE HEALTH INSURING CORPORATION SHALL PROVIDE TO THE 2,093
INDEPENDENT ENTITY ARRANGING FOR THE EXPERTS' REVIEW AND TO THE 2,095
ENROLLEE AND THE ENROLLEE'S PHYSICIAN A COPY OF THOSE MEDICAL 2,096
RECORDS IN THE HEALTH INSURING CORPORATION'S POSSESSION THAT ARE
RELEVANT TO THE ENROLLEE'S CONDITION FOR WHICH THERAPY HAS BEEN 2,099
RECOMMENDED OR REQUESTED. THE MEDICAL RECORDS SHALL BE DISCLOSED 2,100
SOLELY TO THE EXPERT REVIEWERS AND SHALL BE USED SOLELY FOR THE 2,101
PURPOSE OF THIS SECTION. 2,102
(7) THE OPINIONS OF THE EXPERTS ON THE PANEL SHALL BE 2,104
RENDERED WITHIN THIRTY DAYS AFTER THE ENROLLEE'S REQUEST FOR 2,106
REVIEW. IF THE ENROLLEE'S PHYSICIAN DETERMINES THAT A THERAPY 2,108
WOULD BE SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, 2,109
THE OPINIONS SHALL BE RENDERED WITHIN SEVEN DAYS AFTER THE
ENROLLEE'S REQUEST FOR REVIEW. 2,110
(8) EACH EXPERT ON THE PANEL SHALL PROVIDE THE INDEPENDENT 2,112
ENTITY WITH A PROFESSIONAL OPINION AS TO WHETHER THERE IS 2,113
SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE RECOMMENDED OR 2,114
REQUESTED THERAPY IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE 2,115
THAN STANDARD THERAPIES. 2,116
(9) EACH EXPERT'S OPINION SHALL BE PRESENTED IN WRITTEN 2,118
FORM AND SHALL INCLUDE THE FOLLOWING INFORMATION: 2,120
(a) A DESCRIPTION OF THE ENROLLEE'S CONDITION; 2,122
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO 2,124
DETERMINING WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE 2,125
THAT THE RECOMMENDED OR REQUESTED THERAPY IS MORE LIKELY THAN NOT 2,127
TO BE MORE BENEFICIAL TO THE ENROLLEE THAN STANDARD THERAPIES; 2,128
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS 2,130
PUBLISHED IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR 2,131
THE PUBLISHED OPINIONS OF MEDICAL EXPERTS OR SPECIALTY SOCIETIES; 2,132
(d) A DESCRIPTION OF THE ENROLLEE'S SUITABILITY TO RECEIVE 2,134
THE RECOMMENDED OR REQUESTED THERAPY ACCORDING TO A TREATMENT 2,135
PROTOCOL IN A CLINICAL TRIAL, IF APPLICABLE. 2,137
(10) THE INDEPENDENT ENTITY SHALL PROVIDE THE HEALTH 2,139
48
INSURING CORPORATION WITH THE OPINIONS OF THE EXPERTS. THE 2,141
HEALTH INSURING CORPORATION SHALL MAKE THE EXPERTS' OPINIONS
AVAILABLE TO THE ENROLLEE AND THE ENROLLEE'S PHYSICIAN, UPON 2,143
REQUEST.
(11) THE DECISION OF THE MAJORITY OF THE EXPERTS ON THE 2,145
PANEL, RENDERED PURSUANT TO DIVISION (B)(8) OF THIS SECTION, IS 2,146
BINDING ON THE HEALTH INSURING CORPORATION. IF THE OPINIONS OF 2,148
THE EXPERTS ON THE PANEL ARE EVENLY DIVIDED AS TO WHETHER THE 2,149
THERAPY SHOULD BE COVERED, THEN THE HEALTH INSURING CORPORATION'S
FINAL DECISION SHALL BE IN FAVOR OF COVERAGE. IF LESS THAN A 2,152
MAJORITY OF THE EXPERTS ON THE PANEL RECOMMEND COVERAGE OF THE 2,153
THERAPY, THE HEALTH INSURING CORPORATION MAY, IN ITS DISCRETION, 2,154
COVER THE THERAPY. HOWEVER, ANY COVERAGE PROVIDED PURSUANT TO 2,155
DIVISION (B)(11) OF THIS SECTION IS SUBJECT TO THE TERMS AND 2,156
CONDITIONS OF THE ENROLLEE'S CONTRACT WITH THE HEALTH INSURING 2,157
CORPORATION.
(12) THE HEALTH INSURING CORPORATION SHALL HAVE WRITTEN 2,159
POLICIES DESCRIBING THE EXTERNAL, INDEPENDENT REVIEW PROCESS. 2,161
THE HEALTH INSURING CORPORATION SHALL DISCLOSE THE AVAILABILITY 2,162
OF THE EXTERNAL, INDEPENDENT REVIEW PROCESS IN THE HEALTH 2,163
INSURING CORPORATION'S EVIDENCE OF COVERAGE AND DISCLOSURE FORMS. 2,165
(C) IF A HEALTH INSURING CORPORATION'S INITIAL DENIAL OF 2,167
COVERAGE FOR A THERAPY RECOMMENDED OR REQUESTED PURSUANT TO 2,168
DIVISION (A)(3) OF THIS SECTION IS BASED UPON AN EXTERNAL, 2,169
INDEPENDENT REVIEW OF THAT THERAPY MEETING THE REQUIREMENTS OF 2,170
DIVISION (B) OF THIS SECTION, THIS SECTION SHALL NOT BE A BASIS 2,172
FOR REQUIRING A SECOND EXTERNAL, INDEPENDENT REVIEW OF THE
RECOMMENDED OR REQUESTED THERAPY. 2,173
(D) THE HEALTH INSURING CORPORATION SHALL ANNUALLY FILE A 2,175
CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE CERTIFYING ITS 2,176
COMPLIANCE WITH THE REQUIREMENTS OF THIS SECTION. 2,177
Sec. 1753.28. (A) AS USED IN THIS SECTION: 2,179
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL 2,181
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF 2,182
49
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT 2,183
LAYPERSON WITH AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD 2,184
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO 2,185
RESULT IN ANY OF THE FOLLOWING: 2,186
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 2,189
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 2,190
IN SERIOUS JEOPARDY;
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,193
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,196
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING: 2,198
(a) A MEDICAL SCREENING EXAMINATION, AS REQUIRED BY 2,201
FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE EMERGENCY 2,202
DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY 2,203
AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN EMERGENCY 2,204
MEDICAL CONDITION;
(b) SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT THAT 2,207
ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN EMERGENCY MEDICAL 2,208
CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND 2,209
BURN CENTER OF THE HOSPITAL. 2,210
(3)(a) "STABILIZE" MEANS THE PROVISION OF SUCH MEDICAL 2,213
TREATMENT AS MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE 2,214
MEDICAL PROBABILITY, THAT NO MATERIAL DETERIORATION OF AN 2,215
INDIVIDUAL'S MEDICAL CONDITION IS LIKELY TO RESULT FROM OR OCCUR 2,216
DURING A TRANSFER, IF THE MEDICAL CONDITION COULD RESULT IN ANY 2,217
OF THE FOLLOWING:
(i) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 2,220
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 2,221
IN SERIOUS JEOPARDY;
(ii) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,224
(iii) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,227
(b) IN THE CASE OF A WOMAN HAVING CONTRACTIONS, 2,229
"STABILIZE" MEANS SUCH MEDICAL TREATMENT AS MAY BE NECESSARY TO 2,230
DELIVER, INCLUDING THE PLACENTA. 2,231
50
(4) "TRANSFER" HAS THE SAME MEANING AS IN SECTION 1867 OF 2,233
THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 2,235
1395dd, AS AMENDED.
(B) A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 2,237
AGREEMENT PROVIDING COVERAGE OF BASIC HEALTH CARE SERVICES SHALL 2,239
COVER EMERGENCY SERVICES FOR ENROLLEES WITH EMERGENCY MEDICAL 2,240
CONDITIONS WITHOUT REGARD TO THE DAY OR TIME THE EMERGENCY 2,241
SERVICES ARE RENDERED OR TO WHETHER THE ENROLLEE, THE HOSPITAL'S 2,242
EMERGENCY DEPARTMENT WHERE THE SERVICES ARE RENDERED, OR AN 2,243
EMERGENCY PHYSICIAN TREATING THE ENROLLEE, OBTAINED PRIOR 2,244
AUTHORIZATION FOR THE EMERGENCY SERVICES.
(C) A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 2,246
AGREEMENT PROVIDING COVERAGE OF BASIC HEALTH CARE SERVICES SHALL 2,248
COVER BOTH OF THE FOLLOWING:
(1) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A 2,250
PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE 2,251
PRESENTS SELF WITH AN EMERGENCY MEDICAL CONDITION; 2,252
(2) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A 2,254
NONPARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE 2,256
PRESENTS SELF WITH AN EMERGENCY MEDICAL CONDITION AND ONE OF THE 2,257
FOLLOWING CIRCUMSTANCES APPLIES: 2,258
(a) DUE TO CIRCUMSTANCES BEYOND THE ENROLLEE'S CONTROL, 2,261
THE ENROLLEE WAS UNABLE TO UTILIZE A PARTICIPATING HOSPITAL'S
EMERGENCY DEPARTMENT WITHOUT SERIOUS THREAT TO LIFE OR HEALTH. 2,263
(b) A PRUDENT LAYPERSON WITH AN AVERAGE KNOWLEDGE OF 2,266
HEALTH AND MEDICINE WOULD HAVE REASONABLY BELIEVED THAT, UNDER 2,267
THE CIRCUMSTANCES, THE TIME REQUIRED TO TRAVEL TO A PARTICIPATING 2,268
HOSPITAL'S EMERGENCY DEPARTMENT COULD RESULT IN ONE OR MORE OF 2,269
THE ADVERSE HEALTH CONSEQUENCES DESCRIBED IN DIVISION (A)(1) OF 2,270
THIS SECTION.
(c) A PERSON AUTHORIZED BY THE HEALTH INSURING CORPORATION 2,272
REFERS THE ENROLLEE TO AN EMERGENCY DEPARTMENT AND DOES NOT 2,273
SPECIFY A PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT. 2,274
(d) AN AMBULANCE TAKES THE ENROLLEE TO A NONPARTICIPATING 2,276
51
HOSPITAL OTHER THAN AT THE DIRECTION OF THE ENROLLEE. 2,277
(e) THE ENROLLEE IS UNCONSCIOUS. 2,279
(f) A NATURAL DISASTER PRECLUDED THE USE OF A 2,281
PARTICIPATING EMERGENCY DEPARTMENT. 2,282
(g) THE STATUS OF A HOSPITAL CHANGED FROM PARTICIPATING TO 2,284
NONPARTICIPATING WITH RESPECT TO EMERGENCY SERVICES DURING A 2,285
CONTRACT YEAR AND NO GOOD FAITH EFFORT WAS MADE BY THE HEALTH 2,286
INSURING CORPORATION TO INFORM ENROLLEES OF THIS CHANGE. 2,287
(D) A HEALTH INSURING CORPORATION THAT PROVIDES COVERAGE 2,290
FOR EMERGENCY SERVICES SHALL INFORM ENROLLEES OF ALL OF THE 2,291
FOLLOWING:
(1) THE SCOPE OF COVERAGE FOR EMERGENCY SERVICES; 2,293
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES, INCLUDING 2,296
THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE ACCESS 2,297
SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY SERVICES; 2,298
(3) ANY COST SHARING PROVISIONS FOR EMERGENCY SERVICES; 2,300
(4) THE PROCEDURES FOR OBTAINING EMERGENCY SERVICES AND 2,302
OTHER MEDICAL SERVICES, SO THAT ENROLLEES ARE FAMILIAR WITH THE 2,303
LOCATION OF THE EMERGENCY DEPARTMENTS OF PARTICIPATING HOSPITALS 2,304
AND WITH THE LOCATION AND AVAILABILITY OF OTHER PARTICIPATING 2,305
FACILITIES OR SETTINGS AT WHICH THEY COULD RECEIVE MEDICAL 2,306
SERVICES.
Sec. 1753.30. NOTHING IN THIS CHAPTER SHALL PREVENT OR 2,308
OTHERWISE AFFECT THE APPLICATION TO ANY HEALTH CARE PLAN OF THOSE 2,309
PROVISIONS OF TITLE XVII OR XXXIX OF THE REVISED CODE THAT WOULD 2,311
OTHERWISE APPLY.
Sec. 3901.04. (A) As used in this section: 2,320
(1) "Laws of this state relating to insurance" include but 2,322
are not limited to Chapter 1751. notwithstanding section 1751.08, 2,324
CHAPTER 1753., Title XXXIX, sections 5725.18 to 5725.25, and 2,325
Chapter 5729. of the Revised Code. 2,326
(2) "Person" has the meaning defined in division (A) of 2,328
section 3901.19 of the Revised Code. 2,329
(B) Whenever it appears to the superintendent of 2,331
52
insurance, from the superintendent's files, upon complaint or 2,333
otherwise, that any person has engaged in, is engaged in, or is
about to engage in any act or practice declared to be illegal or 2,334
prohibited by the laws of this state relating to insurance, or 2,335
defined as unfair or deceptive by such laws, or when the 2,336
superintendent believes it to be in the best interest of the 2,337
public and necessary for the protection of the people in this 2,338
state, the superintendent or anyone designated by the 2,339
superintendent under the superintendent's official seal may do 2,340
any one or more of the following:
(1) Require any person to file with the superintendent, on 2,342
a form that is appropriate for review by the superintendent, an 2,343
original or additional statement or report in writing, under oath 2,344
or otherwise, as to any facts or circumstances concerning the 2,345
person's conduct of the business of insurance within this state 2,346
and as to any other information that the superintendent considers 2,347
to be material or relevant to such business; 2,348
(2) Administer oaths, summon and compel by order or 2,350
subpoena the attendance of witnesses to testify in relation to 2,351
any matter which, by the laws of this state relating to 2,352
insurance, is the subject of inquiry and investigation, and 2,353
require the production of any book, paper, or document pertaining 2,354
to such matter. A subpoena, notice, or order under this section 2,355
may be served by certified mail, return receipt requested. If 2,356
the subpoena, notice, or order is returned because of inability 2,357
to deliver, or if no return is received within thirty days of the 2,358
date of mailing, the subpoena, notice, or order may be served by 2,359
ordinary mail. If no return of ordinary mail is received within 2,360
thirty days after the date of mailing, service shall be deemed to 2,361
have been made. If the subpoena, notice, or order is returned 2,362
because of inability to deliver, the superintendent may designate 2,363
a person or persons to effect either personal or residence 2,364
service upon the witness. Service of any subpoena, notice, or 2,365
order and return may also be made in any manner authorized under 2,366
53
the Rules of Civil Procedure. Such service shall be made by an 2,367
employee of the department designated by the superintendent, a 2,368
sheriff, a deputy sheriff, an attorney, or any person authorized 2,369
by the Rules of Civil Procedure to serve process. 2,370
In the case of disobedience of any notice, order, or 2,372
subpoena served on a person or the refusal of a witness to 2,373
testify to a matter regarding which the person may lawfully be 2,375
interrogated, the court of common pleas of the county where venue
is appropriate, on application by the superintendent, may compel 2,376
obedience by attachment proceedings for contempt, as in the case 2,377
of disobedience of the requirements of a subpoena issued from 2,378
such court, or a refusal to testify therein. Witnesses shall 2,379
receive the fees and mileage allowed by section 2335.06 of the 2,380
Revised Code. All such fees, upon the presentation of proper 2,381
vouchers approved by the superintendent, shall be paid out of the 2,382
appropriation for the contingent fund of the department of 2,383
insurance. The fees and mileage of witnesses not summoned by the 2,384
superintendent or the superintendent's designee shall not be paid 2,386
by the state.
(3) In a case in which there is no administrative 2,388
procedure available to the superintendent to resolve a matter at 2,389
issue, request the attorney general to commence an action for a 2,390
declaratory judgment under Chapter 2721. of the Revised Code with 2,391
respect to the matter. 2,392
(4) Initiate criminal proceedings by presenting evidence 2,394
of the commission of any criminal offense established under the 2,395
laws of this state relating to insurance to the prosecuting 2,396
attorney of any county in which the offense may be prosecuted. 2,397
At the request of the prosecuting attorney, the attorney general 2,398
may assist in the prosecution of the violation with all the 2,399
rights, privileges, and powers conferred by law on prosecuting 2,400
attorneys including, but not limited to, the power to appear 2,401
before grand juries and to interrogate witnesses before grand 2,402
juries. 2,403
54
Sec. 3901.041. The superintendent of insurance shall 2,413
adopt, amend, and rescind rules and make adjudications, necessary 2,414
to discharge the superintendent's duties and exercise the 2,415
superintendent's powers, including, but not limited to, the 2,416
superintendent's duties and powers under Chapter CHAPTERS 1751. 2,418
AND 1753. and Title XXXIX of the Revised Code, subject to Chapter 2,419
119. of the Revised Code.
Sec. 3901.16. Any association, company, or corporation, 2,429
including a health insuring corporation, which violates any law 2,430
relating to the superintendent of insurance, any provision of 2,431
Chapter 1751. OR 1753. of the Revised Code, or any insurance law 2,433
of this state, for the violation of which no forfeiture or 2,434
penalty is elsewhere provided in the Revised Code, shall forfeit 2,435
and pay not less than one thousand nor more than ten thousand 2,436
dollars, to be recovered by an action in the name of the state 2,437
and on collection to be paid to the superintendent, who shall pay
such sum into the state treasury. 2,438
Sec. 3924.10. (A) The board of directors of the Ohio 2,448
health reinsurance program shall design the SEHC plan which, when 2,450
offered by a carrier, is eligible for reinsurance under the 2,451
program. The board shall establish the form and level of 2,452
coverage to be made available by carriers in their SEHC plan. In 2,453
designing the plan the board shall also establish benefit levels, 2,454
deductibles, coinsurance factors, exclusions, and limitations for 2,455
the plan. The forms and levels of coverage established by the 2,456
board shall specify which components of a health benefit plan 2,457
offered by a carrier may be reinsured. The SEHC plan is subject 2,458
to division (C) of section 3924.02 of the Revised Code and to the 2,460
provisions in Chapters 1751., 1753., 3923., and any other chapter 2,462
of the Revised Code that require coverage or the offer of 2,463
coverage of a health care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 2,466
eighty days after its appointment. The plan may include cost 2,467
containment features including any of the following:
55
(1) Utilization review of health care services, including 2,469
review of the medical necessity of hospital and physician 2,470
services; 2,471
(2) Case management benefit alternatives; 2,473
(3) Selective contracting with hospitals, physicians, and 2,475
other health care providers; 2,476
(4) Reasonable benefit differentials applicable to 2,478
participating and nonparticipating providers; 2,479
(5) Employee assistance program options that provide 2,481
preventive and early intervention mental health and substance 2,482
abuse services; 2,483
(6) Other provisions for the cost-effective management of 2,485
the plan. 2,486
(C) An SEHC plan established for use by health insuring 2,489
corporations shall be consistent with the basic method of 2,491
operation of such corporations.
(D) Each carrier shall certify to the superintendent of 2,493
insurance, in the form and manner prescribed by the 2,494
superintendent, that the SEHC plan filed by the carrier is in 2,496
substantial compliance with the provisions of the board SEHC 2,497
plan. Upon receipt by the superintendent of the certification, 2,498
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 2,500
date that the program becomes operational and as a condition of 2,501
transacting business in this state, renew coverage provided to 2,502
any individual or group under its SEHC plan. 2,503
Section 2. That existing sections 1751.02, 1751.03, 2,505
1751.04, 1751.12, 1751.13, 3901.04, 3901.041, 3901.16, and 2,507
3924.10 of the Revised Code are hereby repealed. 2,508
Section 3. Sections 1 and 2 of this act, except for 2,510
section 1751.12 of the Revised Code, shall take effect October 1, 2,511
1998. Section 1751.12 of the Revised Code shall take effect at 2,512
the earliest time permitted by law.