As Passed by the House 1
122nd General Assembly 4
Regular Session Am. 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
HOUSEHOLDER-LOGAN-MASON-WINKLER-MYERS-OGG-BRITTON-WHALEN- 13
PATTON-CALLENDER-JERSE-MOTTL-REID-DAMSCHRODER-THOMAS- 14
HARRIS-BATEMAN-ROBERTS-AMSTUTZ-BEATTY-VERICH-WILSON- 15
WILLAMOWSKI-JONES-BUCHY-PRENTISS-WESTON 16
18
A B I L L
To amend sections 1751.02 to 1751.04, 1751.12, 20
1751.13, 3901.04, 3901.041, 3901.16, and 3924.10 22
and to enact sections 1751.521, 1751.73 to 23
1751.75, 1751.77 to 1751.86, 1753.01, 1753.03 to 25
1753.10, 1753.14, 1753.16, 1753.21, 1753.23, 26
1753.24, 1753.28, and 1753.30 of the Revised Code 27
to adopt the Physician-Health Plan Partnership 28
Act. 29
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 31
Section 1. That sections 1751.02, 1751.03, 1751.04, 33
1751.12, 1751.13, 3901.04, 3901.041, 3901.16, and 3924.10 be 34
amended and sections 1751.521, 1751.73, 1751.74, 1751.75, 35
1751.77, 1751.78, 1751.79, 1751.80, 1751.81, 1751.82, 1751.83, 36
1751.84, 1751.85, 1751.86, 1753.01, 1753.03, 1753.04, 1753.05, 37
1753.06, 1753.07, 1753.08, 1753.09, 1753.10, 1753.14, 1753.16, 39
1753.21, 1753.23, 1753.24, 1753.28, and 1753.30 of the Revised 41
Code be enacted to read as follows:
Sec. 1751.02. (A) Notwithstanding any law in this state 50
2
to the contrary, any corporation, as defined in section 1751.01 52
of the Revised Code, may apply to the superintendent of insurance 54
for a certificate of authority to establish and operate a health 55
insuring corporation. If the corporation applying for a 56
certificate of authority is a foreign corporation domiciled in a 57
state without laws similar to those of this chapter, the 59
corporation must form a domestic corporation to apply for,
obtain, and maintain a certificate of authority under this 60
chapter.
(B) No person shall establish, operate, or perform the 63
services of a health insuring corporation in this state without 65
obtaining a certificate of authority under this chapter. 66
(C) Except as provided by division (D) of this section, no 69
political subdivision or department, office, or institution of 70
this state, or corporation formed by or on behalf of any
political subdivision or department, office, or institution of 71
this state, shall establish, operate, or perform the services of 72
a health insuring corporation. Nothing in this section shall be 75
construed to preclude a board of county commissioners, a county 76
board of mental retardation and developmental disabilities, an 77
alcohol and drug addiction services board, a board of alcohol, 78
drug addiction, and mental health services, or a community mental 79
health board, or a public entity formed by or on behalf of any of 80
these boards, from using managed care techniques in carrying out 81
the board's or public entity's duties pursuant to the 82
requirements of Chapters 307., 329., 340., and 5126. of the 84
Revised Code. However, no such board or public entity may 86
operate so as to compete in the private sector with health 87
insuring corporations holding certificates of authority under 88
this chapter.
(D) A corporation formed by or on behalf of a publicly 90
owned, operated, or funded hospital or health care facility may 91
apply to the superintendent for a certificate of authority under 93
division (A) of this section to establish and operate a health 94
3
insuring corporation.
(E) A health insuring corporation shall operate in this 97
state in compliance with this chapter AND CHAPTER 1753. OF THE 98
REVISED CODE, and with sections 3702.51 to 3702.62 of the Revised 100
Code, and shall operate in conformity with its filings with the 102
superintendent under this chapter, including filings made 103
pursuant to sections 1751.03, 1751.11, 1751.12, and 1751.31 of 104
the Revised Code. 106
(F) An insurer licensed under Title XXXIX of the Revised 110
Code need not obtain a certificate of authority as a health 111
insuring corporation to offer an open panel plan as long as the 112
providers and health care facilities participating in the open 113
panel plan receive their compensation directly from the insurer. 114
If the providers and health care facilities participating in the 115
open panel plan receive their compensation from any person other 116
than the insurer, or if the insurer offers a closed panel plan, 117
the insurer must obtain a certificate of authority as a health 118
insuring corporation.
(G) An intermediary organization need not obtain a 121
certificate of authority as a health insuring corporation, 122
regardless of the method of reimbursement to the intermediary 123
organization, as long as a health insuring corporation or a 125
self-insured employer maintains the ultimate responsibility to 126
assure delivery of all health care services required by the
contract between the health insuring corporation and the 127
subscriber and the laws of this state or between the self-insured 128
employer and its employees. 129
Nothing in this section shall be construed to require any 131
health care facility, provider, health delivery network, or 132
intermediary organization that contracts with a health insuring 133
corporation or self-insured employer, regardless of the method of 135
reimbursement to the health care facility, provider, health
delivery network, or intermediary organization, to obtain a 136
certificate of authority as a health insuring corporation under 137
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this chapter, unless otherwise provided, in the case of contracts 139
with a self-insured employer, by operation of the "Employee 140
Retirement Income Security Act of 1974," 88 Stat. 829, 29 145
U.S.C.A. 1001, as amended. 147
(H) Any health delivery network doing business in this 150
state that is not required to obtain a certificate of authority 151
under this chapter shall certify to the superintendent annually, 152
not later than the first day of July, and shall provide a 154
statement signed by the highest ranking official which includes 155
the following information:
(1) The health delivery network's full name and the 157
address of its principal place of business; 158
(2) A statement that the health delivery network is not 160
required to obtain a certificate of authority under this chapter 161
to conduct its business. 162
(I) The superintendent shall not issue a certificate of 165
authority to a health insuring corporation that is a provider 166
sponsored organization unless all health care plans to be offered 167
by the health insuring corporation provide basic health care 168
services. Substantially all of the physicians and hospitals with 169
ownership or control of the provider sponsored organization, as 170
defined in division (W) of section 1751.01 of the Revised Code, 173
shall also be participating providers for the provision of basic 174
health care services for health care plans offered by the 175
provider sponsored organization. If a health insuring 176
corporation that is a provider sponsored organization offers 177
health care plans that do not provide basic health care services, 178
the health insuring corporation shall be deemed, for purposes of 179
section 1751.35 of the Revised Code, to have failed to 180
substantially comply with this chapter. 181
Except as specifically provided in this division and in 183
division (C) of section 1751.28 of the Revised Code, the 185
provisions of this chapter shall apply to all health insuring
corporations that are provider sponsored organizations in the 186
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same manner that these provisions apply to all health insuring 187
corporations that are not provider sponsored organizations. 188
(J) Nothing in this section shall be construed to apply to 190
any multiple employer welfare arrangement operating pursuant to 191
Chapter 1739. of the Revised Code. 192
(K) Any person who violates division (B) of this section, 196
and any health delivery network that fails to comply with 197
division (H) of this section, is subject to the penalties set 198
forth in section 1751.45 of the Revised Code. 200
Sec. 1751.03. (A) Each application for a certificate of 210
authority under this chapter shall be verified by an officer or 211
authorized representative of the applicant, shall be in a format 212
prescribed by the superintendent of insurance, and shall set 213
forth or be accompanied by the following: 214
(1) A certified copy of the applicant's articles of 216
incorporation and all amendments to the articles of 217
incorporation; 218
(2) A copy of any regulations adopted for the government 220
of the corporation, any bylaws, and any similar documents, and a 221
copy of all amendments to these regulations, bylaws, and 222
documents. The corporate secretary shall certify that these 223
regulations, bylaws, documents, and amendments have been properly 225
adopted or approved.
(3) A list of the names, addresses, and official positions 228
of the persons responsible for the conduct of the applicant, 229
including all members of the board, the principal officers, and 230
the person responsible for completing or filing financial 231
statements with the department of insurance, accompanied by a 232
completed original biographical affidavit and release of 233
information for each of these persons on forms acceptable to the 234
department;
(4) A full and complete disclosure of the extent and 236
nature of any contractual or other financial arrangement between 237
the applicant and any provider or a person listed in division 238
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(A)(3) of this section, including, but not limited to, a full and 240
complete disclosure of the financial interest held by any such 241
provider or person in any health care facility, provider, or 242
insurer that has entered into a financial relationship with the 243
health insuring corporation; 244
(5) A description of the applicant, its facilities, and 246
its personnel, including, but not limited to, the location, hours 248
of operation, and telephone numbers of all contracted facilities; 249
(6) The applicant's projected annual enrollee population 251
over a three-year period; 252
(7) A clear and specific description of the health care 254
plan or plans to be used by the applicant, including a 255
description of the proposed providers, procedures for accessing 256
care, and the form of all proposed and existing contracts 257
relating to the administration, delivery, or financing of health 258
care services; 259
(8) A copy of each type of evidence of coverage and 261
identification card or similar document to be issued to 262
subscribers; 263
(9) A copy of each type of individual or group policy, 265
contract, or agreement to be used; 266
(10) The schedule of the proposed contractual periodic 268
prepayments or premium rates, or both, accompanied by appropriate 269
supporting data; 270
(11) A financial plan which provides a three-year 272
projection of operating results, including the projected 273
expenses, income, and sources of working capital; 274
(12) The enrollee complaint procedure to be utilized as 276
required under section 1751.19 of the Revised Code; 279
(13) A description of the procedures and programs to be 281
implemented on an ongoing basis to assure the quality of health 282
care services delivered to enrollees, INCLUDING, IF APPLICABLE, A 283
DESCRIPTION OF A QUALITY ASSURANCE PROGRAM COMPLYING WITH THE 285
REQUIREMENTS OF SECTIONS 1751.73 TO 1751.75 OF THE REVISED CODE;
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(14) A statement describing the geographic area or areas 287
to be served, by county; 288
(15) A copy of all solicitation documents; 290
(16) A balance sheet and other financial statements 292
showing the applicant's assets, liabilities, income, and other 293
sources of financial support; 294
(17) A description of the nature and extent of any 296
reinsurance program to be implemented, and a demonstration that 297
errors and omission insurance and, if appropriate, fidelity 298
insurance, will be in place upon the applicant's receipt of a 299
certificate of authority; 300
(18) Copies of all proposed or in force related-party or 302
intercompany agreements with an explanation of the financial 303
impact of these agreements on the applicant. If the applicant 304
intends to enter into a contract for managerial or administrative 306
services, with either an affiliated or an unaffiliated person,
the applicant shall provide a copy of the contract and a detailed 307
description of the person to provide these services. The 309
description shall include that person's experience in managing or 310
administering health care plans, a copy of that person's most 311
recent audited financial statement, and a completed biographical 312
affidavit on a form acceptable to the superintendent for each of 313
that person's principal officers and board members and for any 314
additional employee to be directly involved in providing 315
managerial or administrative services to the health insuring 316
corporation. If the person to provide managerial or 317
administrative services is affiliated with the health insuring 318
corporation, the contract must provide for payment for services 319
based on actual costs.
(19) A statement from the applicant's board that the 321
admitted assets of the applicant have not been and will not be 322
pledged or hypothecated; 323
(20) A statement from the applicant's board that the 325
applicant will submit monthly financial statements during the 326
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first year of operations; 327
(21) The name and address of the applicant's Ohio 330
statutory agent for service of process, notice, or demand; 331
(22) Copies of all documents the applicant filed with the 333
secretary of state; 334
(23) The location of those books and records of the 336
applicant that must be maintained in Ohio; 337
(24) The applicant's federal identification number, 339
corporate address, and mailing address; 340
(25) An internal and external organizational chart; 343
(26) A list of the assets representing the initial net 345
worth of the applicant; 346
(27) If the applicant has a parent company, the parent 348
company's guaranty, on a form acceptable to the superintendent, 349
that the applicant will maintain Ohio's minimum net worth. If no 352
parent company exists, a statement regarding the availability of 353
future funds if needed.
(28) The names and addresses of the applicant's actuary 355
and external auditors; 356
(29) If the applicant is a foreign corporation, a copy of 358
the most recent financial statements filed with the insurance 359
regulatory agency in the applicant's state of domicile; 360
(30) If the applicant is a foreign corporation, a 362
statement from the insurance regulatory agency of the applicant's 363
state of domicile stating that the regulatory agency has no 364
objection to the applicant applying for an Ohio license and that 365
the applicant is in good standing in the applicant's state of 366
domicile; 367
(31) Any other information that the superintendent may 369
require. 370
(B)(1) A health insuring corporation, unless otherwise 373
provided for in this chapter, shall file a timely notice with the 374
superintendent describing any change to the corporation's 375
articles of incorporation or regulations, or any major 376
9
modification to its operations as set out in the information 377
required by division (A) of this section that affects any of the 379
following:
(a) The solvency of the health insuring corporation; 382
(b) The health insuring corporation's continued provision 385
of services that it has contracted to provide; 386
(c) The manner in which the health insuring corporation 389
conducts its business.
(2) If the change or modification is to be the result of 391
an action to be taken by the health insuring corporation, the 392
notice shall be filed with the superintendent prior to the health 393
insuring corporation taking the action. The action shall be 395
deemed approved if the superintendent does not disapprove it 396
within sixty days of filing. 397
(C)(1) No health insuring corporation shall expand its 400
approved service area until a copy of the request for expansion, 401
accompanied by documentation of the network of providers, 402
enrollment projections, plan of operation, and any other changes 403
have been filed with the superintendent. 404
(2) Within ten calendar days after receipt of a complete 406
filing under division (C)(1) of this section, the superintendent 408
shall refer the appropriate jurisdictional issues to the director 409
of health pursuant to section 1751.04 of the Revised Code. 411
(3) Within seventy-five days after the superintendent's 413
receipt of a complete filing under division (C)(1) of this 415
section, the superintendent shall determine whether the plan for 416
expansion is lawful, fair, and reasonable. The superintendent 417
may not make a determination until the superintendent has 418
received the director's certification of compliance, which the 419
director shall furnish within forty-five days after referral 420
under division (C)(2) of this section. The director shall not 422
certify that the requirements of section 1751.04 of the Revised 423
Code are not met, unless the applicant has been given an 425
opportunity for a hearing as provided in division (D) of section 427
10
1751.04 of the Revised Code. The forty-five-day and 428
seventy-five-day review periods provided for in division (C)(3) 430
of this section shall cease to run as of the date on which the 431
notice of the applicant's right to request a hearing is mailed 432
and shall remain suspended until the director issues a final 433
certification. 434
(4) If the superintendent has not approved or disapproved 436
all or a portion of a service area expansion within the 437
seventy-five-day period provided for in division (C)(3) of this 439
section, the filing shall be deemed approved. 440
(5) Disapproval of all or a portion of the filing shall be 443
effected by written notice, which shall state the grounds for the 444
order of disapproval and shall be given in accordance with
Chapter 119. of the Revised Code. 445
Sec. 1751.04. (A) Upon the receipt by the superintendent 456
of insurance of a complete application for a certificate of 457
authority to establish or operate a health insuring corporation, 458
which application sets forth or is accompanied by the information 459
and documents required by division (A) of section 1751.03 of the 461
Revised Code, the superintendent shall transmit copies of the 463
application and accompanying documents to the director of health. 464
(B) The director shall review the application and 467
accompanying documents and make findings as to whether the 468
applicant for a certificate of authority has done all of the 469
following with respect to any basic health care services and 470
supplemental health care services to be furnished: 471
(1) Demonstrated the willingness and potential ability to 473
ensure that all basic health care services and supplemental 474
health care services described in the evidence of coverage will 476
be provided to all its enrollees as promptly as is appropriate 477
and in a manner that assures continuity; 478
(2) Made effective arrangements to ensure that its 480
enrollees have reliable access to qualified providers in those 481
specialties that are generally available in the geographic area 482
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or areas to be served by the applicant and that are necessary to 483
provide all basic health care services and supplemental health 484
care services described in the evidence of coverage; 486
(3) Made appropriate arrangements for the availability of 488
short-term health care services in emergencies within the 489
geographic area or areas to be served by the applicant, 490
twenty-four hours per day, seven days per week, and for the 491
provision of adequate coverage whenever an out-of-area emergency 492
arises; 493
(4) Made appropriate arrangements for an ongoing 495
evaluation and assurance of the quality of health care services 496
provided to enrollees, INCLUDING, IF APPLICABLE, THE DEVELOPMENT 497
OF A QUALITY ASSURANCE PROGRAM COMPLYING WITH THE REQUIREMENTS OF 499
SECTIONS 1751.73 TO 1751.75 OF THE REVISED CODE, and the adequacy
of the personnel, facilities, and equipment by or through which 500
the services are rendered; 501
(5) Developed a procedure to gather and report statistics 503
relating to the cost and effectiveness of its operations, the 504
pattern of utilization of its services, and the quality, 505
availability, and accessibility of its services. 506
(C) Within ninety days of the director's receipt of the 508
application for issuance of a certificate of authority, the 510
director shall certify to the superintendent whether or not the 511
applicant meets the requirements of division (B) of this section 512
and sections 3702.51 to 3702.62 of the Revised Code. If the 513
director certifies that the applicant does not meet these 514
requirements, the director shall specify in what respects it is 515
deficient. However, the director shall not certify that the 516
requirements of this section are not met unless the applicant has 517
been given an opportunity for a hearing. 518
(D) If the applicant requests a hearing, the director 521
shall hold a hearing before certifying that the applicant does 522
not meet the requirements of this section. The hearing shall be 523
held in accordance with Chapter 119. of the Revised Code. 525
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(E) The ninety-day review period provided for under 528
division (C) of this section shall cease to run as of the date on 530
which the notice of the applicant's right to request a hearing is 531
mailed and shall remain suspended until the director issues a 532
final certification order.
Sec. 1751.12. (A)(1) No contractual periodic prepayment 542
and no premium rate for nongroup and conversion policies for 543
health care services, or any amendment to them, may be used by 544
any health insuring corporation at any time until the contractual 545
periodic prepayment and premium rate, or amendment, have been 546
filed with the superintendent of insurance, and shall not be 547
effective until the expiration of sixty days after their filing 548
unless the superintendent sooner gives approval. The 549
superintendent shall disapprove the filing, if the superintendent 550
determines within the sixty-day period that the contractual 551
periodic prepayment or premium rate, or amendment, is not in 552
accordance with sound actuarial principles or is not reasonably 553
related to the applicable coverage and characteristics of the 554
applicable class of enrollees. The superintendent shall notify 555
the health insuring corporation of the disapproval, and it shall 556
thereafter be unlawful for the health insuring corporation to use 557
the contractual periodic prepayment or premium rate, or 558
amendment.
(2) No contractual periodic prepayment for group policies 561
for health care services shall be used until the contractual 562
periodic prepayment has been filed with the superintendent. The 563
superintendent may reject a filing made under division (A)(2) of 564
this section at any time, with at least thirty days' written 565
notice to a health insuring corporation, if the contractual 566
periodic prepayment is not in accordance with sound actuarial 568
principles or is not reasonably related to the applicable 569
coverage and characteristics of the applicable class of 570
enrollees.
(3) At any time, the superintendent, upon at least thirty 572
13
days' written notice to a health insuring corporation, may 573
withdraw the approval given under division (A)(1) of this 574
section, deemed or actual, of any contractual periodic prepayment 576
or premium rate, or amendment, based on information that either 577
of the following applies:
(a) The contractual periodic prepayment or premium rate, 580
or amendment, is not in accordance with sound actuarial 581
principles.
(b) The contractual periodic prepayment or premium rate, 584
or amendment, is not reasonably related to the applicable 585
coverage and characteristics of the applicable class of 586
enrollees.
(4) Any disapproval under division (A)(1) of this section, 588
any rejection of a filing made under division (A)(2) of this 590
section, or any withdrawal of approval under division (A)(3) of 591
this section, shall be effected by a written notice, which shall 592
state the specific basis for the disapproval, rejection, or 593
withdrawal and shall be issued in accordance with Chapter 119. of 594
the Revised Code. 595
(B) Notwithstanding division (A) of this section, a health 598
insuring corporation may use a contractual periodic prepayment or 599
premium rate for policies used for the coverage of beneficiaries 600
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 602
620 (1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare 604
risk contract or medicare cost contract, or for policies used for 605
the coverage of beneficiaries enrolled in the federal employees 606
health benefits program pursuant to 5 U.S.C.A. 8905, or for 609
policies used for the coverage of beneficiaries enrolled in Title 610
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 612
U.S.C.A. 301, as amended, known as the medical assistance program 615
or medicaid, provided by the Ohio department of human services 616
under Chapter 5111. of the Revised Code, or for policies used for 617
the coverage of beneficiaries under any other federal health care 618
program regulated by a federal regulatory body, if both of the 619
14
following apply: 620
(1) The contractual periodic prepayment or premium rate 622
has been approved by the United States department of health and 623
human services, the United States office of personnel management, 625
or the Ohio department of human services.
(2) The contractual periodic prepayment or premium rate is 627
filed with the superintendent prior to use and is accompanied by 628
documentation of approval from the United States department of 630
health and human services, the United States office of personnel 632
management, or the Ohio department of human services. 634
(C) The administrative expense portion of all contractual 637
periodic prepayment or premium rate filings submitted to the 638
superintendent for review must reflect the actual cost of 639
administering the product. The superintendent may require that 640
the administrative expense portion of the filings be itemized and 641
supported.
(D)(1) Copayments and deductibles must be reasonable and 644
must not be a barrier to the necessary utilization of services by 645
enrollees.
(2) A health insuring corporation may not impose copayment 648
charges on basic health care services that exceed thirty per cent 649
of the total cost of providing any single covered health care 650
service, except for PHYSICIAN OFFICE VISITS, emergency health 651
services, and urgent care services. The total cost of providing 652
a health care service is the cost to the health insuring 653
corporation of providing the health care service to the enrollee 654
ITS ENROLLEES as reduced by any applicable provider discount. An 657
open panel plan may not impose copayments on out-of-network
benefits that exceed fifty per cent of the total cost of 658
providing any single covered health care service. 659
(3) To ensure that copayments are not a barrier to the 661
utilization of basic health care services, a health insuring 662
corporation may not impose, in any contract year, on any 663
subscriber or enrollee, copayments that exceed two hundred per 664
15
cent of the total annual premium rate to the subscriber or 665
enrollees. This limitation of two hundred per cent does not 667
include any reasonable copayments that are not a barrier to the 668
necessary utilization of health care services by enrollees and 669
that are imposed on physician office visits, emergency health 670
services, urgent care services, supplemental health care 671
services, or specialty health care services.
(E) A health insuring corporation shall not impose 674
lifetime maximums on basic health care services. However, a 675
health insuring corporation may establish a benefit limit for 676
inpatient hospital services that are provided pursuant to a 677
policy, contract, certificate, or agreement for supplemental 678
health care services.
Sec. 1751.13. (A)(1)(a) A health insuring corporation 688
shall, either directly or indirectly, enter into contracts for 689
the provision of health care services with a sufficient number 690
and types of providers and health care facilities to ensure that 691
all covered health care services will be accessible to enrollees 692
from a contracted provider or health care facility. 693
(b) A HEALTH INSURING CORPORATION SHALL NOT REFUSE TO 696
CONTRACT WITH A PHYSICIAN FOR THE PROVISION OF HEALTH CARE
SERVICES OR REFUSE TO RECOGNIZE A PHYSICIAN AS A SPECIALIST ON 697
THE BASIS THAT THE PHYSICIAN ATTENDED AN EDUCATIONAL PROGRAM OR A 699
RESIDENCY PROGRAM APPROVED OR CERTIFIED BY THE AMERICAN 700
OSTEOPATHIC ASSOCIATION. A HEALTH INSURING CORPORATION SHALL NOT 701
REFUSE TO CONTRACT WITH A HEALTH CARE FACILITY FOR THE PROVISION 702
OF HEALTH CARE SERVICES ON THE BASIS THAT THE HEALTH CARE 703
FACILITY IS CERTIFIED OR ACCREDITED BY THE AMERICAN OSTEOPATHIC 705
ASSOCIATION OR THAT THE HEALTH CARE FACILITY IS AN OSTEOPATHIC 706
HOSPITAL AS DEFINED IN SECTION 3702.51 OF THE REVISED CODE. 709
(c) NOTHING IN DIVISION (A)(1)(b) OF THIS SECTION SHALL BE 713
CONSTRUED TO REQUIRE A HEALTH INSURING CORPORATION TO MAKE A 714
BENEFIT PAYMENT UNDER A CLOSED PANEL PLAN TO A PHYSICIAN OR 715
HEALTH CARE FACILITY WITH WHICH THE HEALTH INSURING CORPORATION 716
16
DOES NOT HAVE A CONTRACT, PROVIDED THAT NONE OF THE BASES SET 717
FORTH IN THAT DIVISION ARE USED AS A REASON FOR FAILING TO MAKE A 718
BENEFIT PAYMENT.
(2) When a health insuring corporation is unable to 720
provide a covered health care service from a contracted provider 721
or health care facility, the health insuring corporation must 722
provide that health care service from a noncontracted provider or 724
health care facility consistent with the terms of the enrollee's 725
policy, contract, certificate, or agreement. The health insuring 726
corporation shall either ensure that the health care service be 727
provided at no greater cost to the enrollee than if the enrollee 728
had obtained the health care service from a contracted provider 729
or health care facility, or make other arrangements acceptable to 730
the superintendent of insurance. 731
(3) Nothing in this section shall prohibit a health 733
insuring corporation from entering into contracts with 734
out-of-state providers or health care facilities that are 735
licensed, certified, accredited, or otherwise authorized in that 736
state. 737
(B)(1) A health insuring corporation shall, either 740
directly or indirectly, enter into contracts with all providers 741
and health care facilities through which health care services are 742
provided to its enrollees.
(2) A health insuring corporation, upon written request, 744
shall assist its contracted providers in finding stop-loss or 745
reinsurance carriers.
(C) A health insuring corporation shall file an annual 747
certificate with the superintendent certifying that all provider 748
contracts and contracts with health care facilities through which 749
health care services are being provided contain the following: 750
(1) A description of the method by which the provider or 752
health care facility will be notified of the specific health care 754
services for which the provider or health care facility will be 755
responsible, including any limitations or conditions on such 756
17
services;
(2) The specific hold harmless provision specifying 758
protection of enrollees set forth as follows: 759
"[Provider/Health Care Facility< agrees that in no event, 762
including but not limited to nonpayment by the health insuring 763
corporation, insolvency of the health insuring corporation, or 764
breach of this agreement, shall [Provider/Health Care Facility< 766
bill, charge, collect a deposit from, seek remuneration or 767
reimbursement from, or have any recourse against, a subscriber, 768
enrollee, person to whom health care services have been provided, 770
or person acting on behalf of the covered enrollee, for health 771
care services provided pursuant to this agreement. This does not 772
prohibit [Provider/Health Care Facility< from collecting 773
co-insurance, deductibles, or copayments as specifically provided 775
in the evidence of coverage, or fees for uncovered health care 776
services delivered on a fee-for-service basis to persons 777
referenced above, nor from any recourse against the health 778
insuring corporation or its successor."
(3) Provisions requiring the provider or health care 780
facility to continue to provide covered health care services to 781
enrollees in the event of the health insuring corporation's 782
insolvency or discontinuance of operations. The provisions shall 784
require the provider or health care facility to continue to 785
provide covered health care services to enrollees as needed to 786
complete any medically necessary procedures commenced but 787
unfinished at the time of the health insuring corporation's
insolvency or discontinuance of operations. If an enrollee is 788
receiving necessary inpatient care at a hospital, the provisions 789
may limit the required provision of covered health care services 790
relating to that inpatient care in accordance with division 791
(D)(3) of section 1751.11 of the Revised Code, and may also limit 793
such required provision of covered health care services to the 794
period ending thirty days after the health insuring corporation's 795
insolvency or discontinuance of operations. 796
18
The provisions required by division (C)(3) of this section 799
shall not require any provider or health care facility to 800
continue to provide any covered health care service after the
occurrence of any of the following: 801
(a) The end of the thirty-day period following the entry 803
of a liquidation order under Chapter 3903. of the Revised Code; 805
(b) The end of the enrollee's period of coverage for a 807
contractual prepayment or premium; 808
(c) The enrollee obtains equivalent coverage with another 810
health insuring corporation or insurer, or the enrollee's 811
employer obtains such coverage for the enrollee; 812
(d) The enrollee or the enrollee's employer terminates 814
coverage under the contract; 815
(e) A liquidator effects a transfer of the health insuring 818
corporation's obligations under the contract under division 819
(A)(8) of section 3903.21 of the Revised Code.
(4) A provision clearly stating the rights and 821
responsibilities of the health insuring corporation, and of the 822
contracted providers and health care facilities, with respect to 823
administrative policies and programs, including, but not limited 824
to, payments systems, utilization review, quality ASSURANCE, 825
assessment, and improvement programs, credentialing, 826
confidentiality requirements, and any applicable federal or state 827
programs; 828
(5) A provision regarding the availability and 830
confidentiality of those health records maintained by providers 831
and health care facilities to monitor and evaluate the quality of 833
care, to conduct evaluations and audits, and to determine on a 834
concurrent or retrospective basis the necessity of and
appropriateness of health care services provided to enrollees. 835
The provision shall include terms requiring the provider or 836
health care facility to make these health records available to 837
appropriate state and federal authorities involved in assessing 838
the quality of care or in investigating the grievances or 839
19
complaints of enrollees, and requiring the provider or health 840
care facility to comply with applicable state and federal laws 841
related to the confidentiality of medical or health records. 843
(6) A provision that states that contractual rights and 845
responsibilities may not be assigned or delegated by the provider 847
or health care facility without the prior written consent of the 848
health insuring corporation;
(7) A provision requiring the provider or health care 850
facility to maintain adequate professional liability and 851
malpractice insurance. The provision shall also require the 852
provider or health care facility to notify the health insuring 853
corporation not more than ten days after the provider's or health 855
care facility's receipt of notice of any reduction or
cancellation of such coverage. 856
(8) A provision requiring the provider or health care 858
facility to observe, protect, and promote the rights of enrollees 860
as patients;
(9) A provision requiring the provider or health care 862
facility to provide health care services without discrimination 863
on the basis of a patient's participation in the health care 864
plan, age, sex, ethnicity, religion, sexual preference, health 865
status, or disability, and without regard to the source of 866
payments made for health care services rendered to a patient. 867
This requirement shall not apply to circumstances when the 868
provider or health care facility appropriately does not render 869
services due to limitations arising from the provider's or health 871
care facility's lack of training, experience, or skill, or due to 872
licensing restrictions.
(10) A provision containing the specifics of any 874
obligation on the provider or health care facility to provide, or 876
to arrange for the provision of, covered health care services
twenty-four hours per day, seven days per week; 877
(11) A provision setting forth procedures for the 879
resolution of disputes arising out of the contract; 880
20
(12) A provision stating that the hold harmless provision 882
required by division (C)(2) of this section shall survive the 884
termination of the contract with respect to services covered and 885
provided under the contract during the time the contract was in 886
effect, regardless of the reason for the termination, including
the insolvency of the health insuring corporation; 887
(13) A provision requiring those terms that are used in 889
the contract and that are defined by this chapter, be used in the 891
contract in a manner consistent with those definitions. 892
(D)(1) No health insuring corporation contract with a 895
provider or health care facility shall do either CONTAIN ANY of 896
the following:
(1) Offer (a) A PROVISION THAT DIRECTLY OR INDIRECTLY 898
OFFERS an inducement to the provider or health care facility, 900
directly or indirectly, to reduce or limit medically necessary 901
health care services to a covered enrollee;
(2) Penalize (b) A PROVISION THAT PENALIZES a provider or 904
health care facility that assists an enrollee to seek a 905
reconsideration of the health insuring corporation's decision to 906
deny or limit benefits to the enrollee; 907
(c) A PROVISION THAT LIMITS OR OTHERWISE RESTRICTS THE 910
PROVIDER'S OR HEALTH CARE FACILITY'S ETHICAL AND LEGAL
RESPONSIBILITY TO FULLY ADVISE ENROLLEES ABOUT THEIR MEDICAL 911
CONDITION AND ABOUT MEDICALLY APPROPRIATE TREATMENT OPTIONS; 913
(d) A PROVISION THAT PENALIZES A PROVIDER OR HEALTH CARE 916
FACILITY FOR PRINCIPALLY ADVOCATING FOR MEDICALLY NECESSARY 917
HEALTH CARE SERVICES;
(e) A PROVISION THAT PENALIZES A PROVIDER OR HEALTH CARE 919
FACILITY FOR PROVIDING INFORMATION OR TESTIMONY TO A LEGISLATIVE 920
OR REGULATORY BODY OR AGENCY. THIS SHALL NOT BE CONSTRUED TO 921
PROHIBIT A HEALTH INSURING CORPORATION FROM PENALIZING A PROVIDER 923
OR HEALTH CARE FACILITY THAT PROVIDES INFORMATION OR TESTIMONY 924
THAT IS LIBELOUS OR SLANDEROUS OR THAT DISCLOSES TRADE SECRETS 925
WHICH THE PROVIDER OR HEALTH CARE FACILITY HAS NO PRIVILEGE OR 926
21
PERMISSION TO DISCLOSE.
(2) NOTHING IN THIS DIVISION SHALL BE CONSTRUED TO 928
PROHIBIT A HEALTH INSURING CORPORATION FROM DOING EITHER OF THE 929
FOLLOWING: 930
(a) MAKING A DETERMINATION NOT TO REIMBURSE OR PAY FOR A 933
PARTICULAR MEDICAL TREATMENT OR OTHER HEALTH CARE SERVICE; 934
(b) ENFORCING REASONABLE PEER REVIEW OR UTILIZATION REVIEW 937
PROTOCOLS, OR DETERMINING WHETHER A PARTICULAR PROVIDER OR HEALTH 938
CARE FACILITY HAS COMPLIED WITH THESE PROTOCOLS. 939
(E) Any contract between a health insuring corporation and 942
an intermediary organization shall clearly specify that the 943
health insuring corporation must approve or disapprove the 944
participation of any provider or health care facility with which 945
the intermediary organization contracts. 946
(F) If an intermediary organization that is not a health 948
delivery network contracting solely with self-insured employers 949
subcontracts with a provider or health care facility, the 950
subcontract with the provider or health care facility shall do 951
all of the following:
(1) Contain the provisions required by divisions (C) and 954
(G) of this section, as made applicable to an intermediary 955
organization, without the inclusion of inducements or penalties 956
described in division (D) of this section; 957
(2) Acknowledge that the health insuring corporation is a 959
third-party beneficiary to the agreement; 960
(3) Acknowledge the health insuring corporation's role in 962
approving the participation of the provider or health care 963
facility, pursuant to division (E) of this section. 965
(G) Any provider contract or contract with a health care 968
facility shall clearly specify the health insuring corporation's 969
statutory responsibility to monitor and oversee the offering of 970
covered health care services to its enrollees. 971
(H)(1) A health insuring corporation shall maintain its 974
provider contracts and its contracts with health care facilities 975
22
at one or more of its places of business in this state, and shall 976
provide copies of these contracts to facilitate regulatory review 977
upon written notice by the superintendent of insurance. 978
(2) Any contract with an intermediary organization shall 980
include provisions requiring the intermediary organization to 981
provide the superintendent with regulatory access to all books, 982
records, financial information, and documents related to the 983
provision of health care services to subscribers and enrollees 984
under the contract. The contract shall require the intermediary 985
organization to maintain such books, records, financial 986
information, and documents at its principal place of business in 987
this state and to preserve them for at least three years in a 988
manner that facilitates regulatory review. 989
(I) A health insuring corporation shall provide notice of 992
the termination of any contract with a primary care physician or 993
hospital.
(J) Divisions (A) and (B) of this section do not apply to 996
any health insuring corporation that, on the effective date of 997
this section JUNE 4, 1997, holds a certificate of authority or 998
license to operate under Chapter 1740. of the Revised Code. 1,000
(K) NOTHING IN THIS SECTION SHALL RESTRICT THE GOVERNING 1,002
BODY OF A HOSPITAL FROM EXERCISING THE AUTHORITY GRANTED IT 1,003
PURSUANT TO SECTION 3701.351 OF THE REVISED CODE. 1,004
Sec. 1751.521. IF AN ENROLLEE SIGNS A MEDICAL INFORMATION 1,006
RELEASE UPON THE REQUEST OF A HEALTH INSURING CORPORATION, THE 1,007
RELEASE SHALL CLEARLY EXPLAIN WHAT INFORMATION MAY BE DISCLOSED 1,008
UNDER THE TERMS OF THE RELEASE. IF A HEALTH INSURING CORPORATION 1,009
UTILIZES THIS RELEASE TO REQUEST MEDICAL INFORMATION FROM A 1,010
HEALTH CARE FACILITY OR PROVIDER, THE HEALTH INSURING CORPORATION
SHALL PROVIDE A COPY OF THE ENROLLEE'S RELEASE TO THE HEALTH CARE 1,011
FACILITY OR PROVIDER, UPON REQUEST. 1,012
Sec. 1751.73. EACH HEALTH INSURING CORPORATION PROVIDING 1,015
BASIC HEALTH CARE SERVICES SHALL IMPLEMENT A QUALITY ASSURANCE 1,016
PROGRAM FOR USE IN CONNECTION WITH THOSE POLICIES, CONTRACTS, AND 1,017
23
AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES. EACH HEALTH 1,018
INSURING CORPORATION REQUIRED TO IMPLEMENT A QUALITY ASSURANCE 1,019
PROGRAM SHALL ANNUALLY FILE A CERTIFICATE WITH THE SUPERINTENDENT 1,020
OF INSURANCE CERTIFYING THAT ITS QUALITY ASSURANCE PROGRAM DOES 1,021
ALL OF THE FOLLOWING:
(A) IDENTIFIES A CORPORATE BOARD OR COMMITTEE OR 1,023
DESIGNATES AN EXECUTIVE STAFF PERSON RESPONSIBLE FOR PROGRAM 1,024
IMPLEMENTATION AND COMPLIANCE;
(B) INCLUDES A PROCESS ENABLING THE SELECTION AND 1,026
RETENTION OF QUALITY PROVIDERS AND HEALTH CARE FACILITIES THROUGH 1,027
CREDENTIALING, RECREDENTIALING, AND MONITORING PROCEDURES; 1,028
(C) PROVIDES FOR ONGOING MONITORING OF THE QUALITY 1,030
ASSURANCE PROGRAM; 1,031
(D) ASSURES A PROCESS FOR COMPLIANCE BY ANY ENTITY OR 1,033
ENTITIES WITH WHICH THE HEALTH INSURING CORPORATION CONTRACTS FOR 1,034
SERVICES;
(E) INCLUDES A PROCESS TO TAKE REMEDIAL ACTION TO CORRECT 1,036
QUALITY PROBLEMS. 1,037
Sec. 1751.74. (A) TO IMPLEMENT A QUALITY ASSURANCE 1,039
PROGRAM REQUIRED BY SECTION 1715.73 OF THE REVISED CODE, A HEALTH 1,040
INSURING CORPORATION SHALL DO BOTH OF THE FOLLOWING: 1,041
(1) DEVELOP AND MAINTAIN THE APPROPRIATE INFRASTRUCTURE 1,044
AND DISCLOSURE SYSTEMS NECESSARY TO MEASURE AND REPORT, ON A 1,045
REGULAR BASIS, THE QUALITY OF HEALTH CARE SERVICES PROVIDED TO 1,046
ENROLLEES, BASED ON A SYSTEMATIC COLLECTION, ANALYSIS, AND 1,047
REPORTING OF RELEVANT DATA. THE HEALTH INSURING CORPORATION 1,048
SHALL ASSURE THAT A COMMITTEE THAT INCLUDES PARTICIPATING 1,049
PHYSICIANS HAVE THE OPPORTUNITY TO PARTICIPATE IN DEVELOPING, 1,050
IMPLEMENTING, AND EVALUATING THE QUALITY ASSURANCE PROGRAM AND 1,052
ALL OTHER PROGRAMS IMPLEMENTED BY THE HEALTH INSURING CORPORATION
THAT RELATE TO THE UTILIZATION OF HEALTH CARE SERVICES. A 1,054
COMMITTEE THAT INCLUDES PARTICIPATING PHYSICIANS SHALL ALSO HAVE 1,055
THE OPPORTUNITY TO PARTICIPATE IN THE DERIVATION OF DATA 1,056
ASSESSMENTS, STATISTICAL ANALYSES, AND OUTCOME INTERPRETATIONS 1,058
24
FROM PROGRAMS MONITORING THE UTILIZATION OF HEALTH CARE SERVICES. 1,059
(2) DEVELOP AND MAINTAIN AN ORGANIZATIONAL PROGRAM FOR 1,062
DESIGNING, MEASURING, ASSESSING, AND IMPROVING THE PROCESSES AND 1,063
OUTCOMES OF HEALTH CARE.
(B) A QUALITY ASSURANCE PROGRAM SHALL: 1,065
(1) ESTABLISH AN INTERNAL SYSTEM CAPABLE OF IDENTIFYING 1,067
OPPORTUNITIES TO IMPROVE HEALTH CARE, WHICH SYSTEM IS STRUCTURED 1,068
TO IDENTIFY PRACTICES THAT RESULT IN IMPROVED HEALTH CARE 1,069
OUTCOMES, TO IDENTIFY PROBLEMATIC UTILIZATION PATTERNS, AND TO 1,070
IDENTIFY THOSE PROVIDERS THAT MAY BE RESPONSIBLE FOR EITHER 1,071
EXEMPLARY OR PROBLEMATIC PATTERNS. THE QUALITY ASSURANCE PROGRAM 1,072
SHALL USE THE FINDINGS GENERATED BY THE SYSTEM TO WORK ON A 1,074
CONTINUING BASIS WITH PARTICIPATING PROVIDERS AND OTHER STAFF TO 1,075
IMPROVE THE QUALITY OF HEALTH CARE SERVICES PROVIDED TO 1,077
ENROLLEES.
(2) DEVELOP A WRITTEN STATEMENT OF ITS OBJECTIVES, LINES 1,079
OF AUTHORITY AND ACCOUNTABILITY, EVALUATION TOOLS, AND 1,080
PERFORMANCE IMPROVEMENT ACTIVITIES; 1,081
(3) REQUIRE AN ANNUAL EFFECTIVENESS REVIEW OF THE PROGRAM; 1,084
(4) PROVIDE A DESCRIPTION OF HOW THE HEALTH INSURING 1,087
CORPORATION INTENDS TO DO ALL OF THE FOLLOWING: 1,088
(a) ANALYZE BOTH PROCESSES AND OUTCOMES OF HEALTH CARE, 1,090
INCLUDING FOCUSED REVIEW OF INDIVIDUAL CASES AS APPROPRIATE, TO 1,092
DISCERN THE CAUSES OF VARIATION;
(b) IDENTIFY THE TARGETED DIAGNOSES AND TREATMENTS TO BE 1,094
REVIEWED BY THE QUALITY ASSURANCE PROGRAM EACH YEAR, BASED ON 1,095
CONSIDERATION OF PRACTICES AND DIAGNOSES THAT AFFECT A 1,096
SUBSTANTIAL NUMBER OF THE HEALTH INSURING CORPORATION'S ENROLLEES 1,097
OR THAT COULD PLACE ENROLLEES AT SERIOUS RISK; 1,098
(c) USE A RANGE OF APPROPRIATE METHODS TO ANALYZE QUALITY 1,100
OF HEALTH CARE, INCLUDING COLLECTION AND ANALYSIS OF INFORMATION 1,102
ON OVER-UTILIZATION AND UNDER-UTILIZATION OF HEALTH CARE 1,103
SERVICES; EVALUATION OF COURSES OF TREATMENT AND OUTCOMES BASED 1,105
ON CURRENT MEDICAL RESEARCH, KNOWLEDGE, STANDARDS, AND PRACTICE
25
GUIDELINES; AND COLLECTION AND ANALYSIS OF INFORMATION SPECIFIC 1,106
TO ENROLLEES OR PROVIDERS; 1,107
(d) COMPARE QUALITY ASSURANCE PROGRAM FINDINGS WITH PAST 1,109
PERFORMANCE, INTERNAL GOALS, AND EXTERNAL STANDARDS; 1,111
(e) MEASURE THE PERFORMANCE OF PARTICIPATING PROVIDERS AND 1,113
CONDUCT PEER REVIEW ACTIVITIES; 1,114
(f) UTILIZE TREATMENT PROTOCOLS AND PRACTICE PARAMETERS 1,116
DEVELOPED WITH APPROPRIATE CLINICAL INPUT; 1,117
(g) IMPLEMENT IMPROVEMENT STRATEGIES RELATED TO QUALITY 1,119
ASSURANCE PROGRAM FINDINGS; 1,120
(h) EVALUATE PERIODICALLY, BUT NOT LESS THAN ANNUALLY, THE 1,122
EFFECTIVENESS OF THE IMPROVEMENT STRATEGIES. 1,123
Sec. 1751.75. A HEALTH INSURING CORPORATION MAY PRESENT 1,125
EVIDENCE OF COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1751.73 1,126
AND 1751.74 OF THE REVISED CODE BY SUBMITTING CERTIFICATION TO 1,127
THE SUPERINTENDENT OF INSURANCE OF ITS ACCREDITATION BY AN 1,128
INDEPENDENT, PRIVATE ACCREDITING ORGANIZATION, SUCH AS THE
NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION ON 1,129
ACCREDITATION OF HEALTH CARE ORGANIZATIONS, OR THE AMERICAN 1,130
ACCREDITATION HEALTHCARE COMMISSION/UTILIZATION REVIEW 1,132
ACCREDITATION COMMISSION. THE SUPERINTENDENT, UPON REVIEW OF THE 1,133
ORGANIZATION'S ACCREDITATION PROCESS, MAY DETERMINE THAT SUCH 1,134
ACCREDITATION CONSTITUTES COMPLIANCE BY THE HEALTH INSURING 1,135
CORPORATION WITH THE REQUIREMENTS OF THESE SECTIONS. 1,136
Sec. 1751.77. AS USED IN SECTIONS 1751.77 TO 1751.86 OF 1,138
THE REVISED CODE, UNLESS OTHERWISE SPECIFICALLY PROVIDED: 1,139
(A) "ADVERSE DETERMINATION" MEANS A DETERMINATION BY A 1,141
HEALTH INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,142
ORGANIZATION THAT AN ADMISSION, AVAILABILITY OF CARE, CONTINUED 1,144
STAY, OR OTHER HEALTH CARE SERVICE COVERED UNDER A POLICY, 1,145
CONTRACT, OR AGREEMENT OF THE HEALTH INSURING CORPORATION HAS 1,147
BEEN REVIEWED AND, BASED UPON THE INFORMATION PROVIDED, THE 1,148
HEALTH CARE SERVICE DOES NOT MEET THE HEALTH INSURING 1,150
CORPORATION'S REQUIREMENTS FOR BENEFIT PAYMENT, AND IS THEREFORE 1,151
26
DENIED, REDUCED, OR TERMINATED.
(B) "AMBULATORY REVIEW" MEANS UTILIZATION REVIEW OF HEALTH 1,153
CARE SERVICES PERFORMED OR PROVIDED IN AN OUTPATIENT SETTING. 1,154
(C) "CASE MANAGEMENT" MEANS A COORDINATED SET OF 1,156
ACTIVITIES CONDUCTED FOR INDIVIDUAL PATIENT MANAGEMENT OF 1,157
SERIOUS, COMPLICATED, PROTRACTED, OR OTHER SPECIFIED HEALTH 1,158
CONDITIONS.
(D) "CERTIFICATION" MEANS A DETERMINATION BY A HEALTH 1,160
INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,162
ORGANIZATION THAT AN ADMISSION, AVAILABILITY OF CARE, CONTINUED 1,163
STAY, OR OTHER HEALTH CARE SERVICE COVERED UNDER A POLICY, 1,164
CONTRACT, OR AGREEMENT OF THE HEALTH INSURING CORPORATION HAS 1,166
BEEN REVIEWED AND, BASED UPON THE INFORMATION PROVIDED, THE 1,167
HEALTH CARE SERVICE SATISFIES THE HEALTH INSURING CORPORATION'S 1,168
REQUIREMENTS FOR BENEFIT PAYMENT. 1,169
(E) "CLINICAL PEER" MEANS A PHYSICIAN WHEN AN EVALUATION 1,172
IS TO BE MADE OF THE CLINICAL APPROPRIATENESS OF HEALTH CARE 1,173
SERVICES PROVIDED BY A PHYSICIAN. IF AN EVALUATION IS TO BE MADE 1,174
OF THE CLINICAL APPROPRIATENESS OF HEALTH CARE SERVICES PROVIDED 1,175
BY A PROVIDER WHO IS NOT A PHYSICIAN, "CLINICAL PEER" MEANS 1,176
EITHER A PHYSICIAN OR A PROVIDER HOLDING THE SAME LICENSE AS THE 1,177
PROVIDER WHO PROVIDED THE HEALTH CARE SERVICES. 1,178
(F) "CLINICAL REVIEW CRITERIA" MEANS THE WRITTEN SCREENING 1,180
PROCEDURES, DECISION ABSTRACTS, CLINICAL PROTOCOLS, AND PRACTICE 1,181
GUIDELINES USED BY A HEALTH INSURING CORPORATION TO DETERMINE THE 1,182
NECESSITY AND APPROPRIATENESS OF HEALTH CARE SERVICES. 1,184
(G) "CONCURRENT REVIEW" MEANS UTILIZATION REVIEW CONDUCTED 1,186
DURING A PATIENT'S HOSPITAL STAY OR COURSE OF TREATMENT. 1,187
(H) "DISCHARGE PLANNING" MEANS THE FORMAL PROCESS FOR 1,189
DETERMINING, PRIOR TO A PATIENT'S DISCHARGE FROM A HEALTH CARE 1,190
FACILITY, THE COORDINATION AND MANAGEMENT OF THE CARE THAT THE 1,192
PATIENT IS TO RECEIVE FOLLOWING DISCHARGE FROM A HEALTH CARE 1,193
FACILITY. 1,194
(I) "PARTICIPATING PROVIDER" MEANS A PROVIDER OR HEALTH 1,196
27
CARE FACILITY THAT, UNDER A CONTRACT WITH A HEALTH INSURING 1,198
CORPORATION OR WITH ITS CONTRACTOR OR SUBCONTRACTOR, HAS AGREED 1,200
TO PROVIDE HEALTH CARE SERVICES TO ENROLLEES WITH AN EXPECTATION
OF RECEIVING PAYMENT, OTHER THAN COINSURANCE, COPAYMENTS, OR 1,201
DEDUCTIBLES, DIRECTLY OR INDIRECTLY FROM THE HEALTH INSURING 1,202
CORPORATION.
(J) "PHYSICIAN" MEANS A PROVIDER AUTHORIZED UNDER CHAPTER 1,205
4731. OF THE REVISED CODE TO PRACTICE MEDICINE AND SURGERY OR 1,208
OSTEOPATHIC MEDICINE AND SURGERY.
(K) "PROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW THAT IS 1,210
CONDUCTED PRIOR TO AN ADMISSION OR A COURSE OF TREATMENT. 1,211
(L) "RETROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW OF 1,213
MEDICAL NECESSITY THAT IS CONDUCTED AFTER HEALTH CARE SERVICES 1,214
HAVE BEEN PROVIDED TO A PATIENT. "RETROSPECTIVE REVIEW" DOES NOT 1,216
INCLUDE THE REVIEW OF A CLAIM THAT IS LIMITED TO AN EVALUATION OF 1,217
REIMBURSEMENT LEVELS, VERACITY OF DOCUMENTATION, ACCURACY OF 1,218
CODING, OR ADJUDICATION OF PAYMENT.
(M) "SECOND OPINION" MEANS AN OPPORTUNITY OR REQUIREMENT 1,220
TO OBTAIN A CLINICAL EVALUATION BY A PROVIDER OTHER THAN THE 1,221
PROVIDER ORIGINALLY MAKING A RECOMMENDATION FOR PROPOSED HEALTH 1,222
CARE SERVICES TO ASSESS THE CLINICAL NECESSITY AND 1,223
APPROPRIATENESS OF THE PROPOSED HEALTH CARE SERVICES. 1,224
(N) "UTILIZATION REVIEW" MEANS A PROCESS USED TO MONITOR 1,226
THE USE OF, OR EVALUATE THE CLINICAL NECESSITY, APPROPRIATENESS, 1,227
EFFICACY, OR EFFICIENCY OF, HEALTH CARE SERVICES, PROCEDURES, OR 1,228
SETTINGS. AREAS OF REVIEW MAY INCLUDE AMBULATORY REVIEW, 1,229
PROSPECTIVE REVIEW, SECOND OPINION, CERTIFICATION, CONCURRENT 1,230
REVIEW, CASE MANAGEMENT, DISCHARGE PLANNING, OR RETROSPECTIVE 1,231
REVIEW.
(O) "UTILIZATION REVIEW ORGANIZATION" MEANS AN ENTITY THAT 1,233
CONDUCTS UTILIZATION REVIEW, OTHER THAN A HEALTH INSURING 1,234
CORPORATION PERFORMING A REVIEW OF ITS OWN HEALTH CARE PLANS. 1,236
Sec. 1751.78. (A)(1) SECTIONS 1751.77 TO 1751.86 OF THE 1,239
REVISED CODE APPLY TO ANY HEALTH INSURING CORPORATION THAT 1,240
28
PROVIDES OR PERFORMS UTILIZATION REVIEW SERVICES IN CONNECTION 1,241
WITH ITS POLICIES, CONTRACTS, AND AGREEMENTS PROVIDING BASIC
HEALTH CARE SERVICES AND TO ANY DESIGNEE OF THE HEALTH INSURING 1,242
CORPORATION, OR TO ANY UTILIZATION REVIEW ORGANIZATION THAT 1,244
PERFORMS UTILIZATION REVIEW FUNCTIONS ON BEHALF OF THE HEALTH 1,245
INSURING CORPORATION IN CONNECTION WITH POLICIES, CONTRACTS, OR 1,246
AGREEMENTS OF THE HEALTH INSURING CORPORATION PROVIDING BASIC
HEALTH CARE SERVICES. 1,247
(2) NOTHING IN SECTIONS 1751.77 TO 1751.82 OR SECTION 1,249
1751.85 OF THE REVISED CODE SHALL BE CONSTRUED TO REQUIRE A 1,251
HEALTH INSURING CORPORATION TO PROVIDE OR PERFORM UTILIZATION 1,252
REVIEW SERVICES IN CONNECTION WITH HEALTH CARE SERVICES PROVIDED 1,253
UNDER A POLICY, PLAN, OR AGREEMENT OF SUPPLEMENTAL HEALTH CARE 1,254
SERVICES OR SPECIALTY HEALTH CARE SERVICES. 1,255
(B)(1) EACH HEALTH INSURING CORPORATION SHALL BE 1,258
RESPONSIBLE FOR MONITORING ALL UTILIZATION REVIEW ACTIVITIES 1,259
CARRIED OUT BY, OR ON BEHALF OF, THE HEALTH INSURING CORPORATION 1,260
AND FOR ENSURING THAT ALL REQUIREMENTS OF SECTIONS 1751.77 TO 1,261
1751.86 OF THE REVISED CODE, AND ANY RULES ADOPTED THEREUNDER, 1,263
ARE MET. THE HEALTH INSURING CORPORATION SHALL ALSO ENSURE THAT
APPROPRIATE PERSONNEL HAVE OPERATIONAL RESPONSIBILITY FOR THE 1,264
CONDUCT OF THE HEALTH INSURING CORPORATION'S UTILIZATION REVIEW 1,265
PROGRAM. 1,266
(2) IF A HEALTH INSURING CORPORATION CONTRACTS TO HAVE A 1,268
UTILIZATION REVIEW ORGANIZATION OR OTHER ENTITY PERFORM THE 1,269
UTILIZATION REVIEW FUNCTIONS REQUIRED BY SECTIONS 1751.77 TO 1,270
1751.86 OF THE REVISED CODE, AND ANY RULES ADOPTED THEREUNDER, 1,273
THE SUPERINTENDENT OF INSURANCE SHALL HOLD THE HEALTH INSURING 1,274
CORPORATION RESPONSIBLE FOR MONITORING THE ACTIVITIES OF THE
UTILIZATION REVIEW ORGANIZATION OR OTHER ENTITY AND FOR ENSURING 1,275
THAT THE REQUIREMENTS OF THOSE SECTIONS AND RULES ARE MET. 1,277
Sec. 1751.79. A HEALTH INSURING CORPORATION THAT CONDUCTS 1,279
UTILIZATION REVIEW SHALL PREPARE A WRITTEN UTILIZATION REVIEW 1,280
PROGRAM THAT DESCRIBES ALL REVIEW ACTIVITIES, BOTH DELEGATED AND 1,281
29
NONDELEGATED, FOR COVERED HEALTH CARE SERVICES PROVIDED, 1,283
INCLUDING THE FOLLOWING:
(A) PROCEDURES TO EVALUATE THE CLINICAL NECESSITY, 1,285
APPROPRIATENESS, EFFICACY, OR EFFICIENCY OF HEALTH CARE SERVICES; 1,287
(B) THE USE OF DATA SOURCES AND CLINICAL REVIEW CRITERIA 1,289
IN MAKING DECISIONS; 1,291
(C) MECHANISMS TO ENSURE CONSISTENT APPLICATION OF 1,293
CRITERIA AND COMPATIBLE DECISIONS; 1,294
(D) DATA COLLECTION PROCESSES AND ANALYTICAL METHODS USED 1,296
IN ASSESSING UTILIZATION OF HEALTH CARE SERVICES; 1,298
(E) MECHANISMS FOR ASSURING CONFIDENTIALITY OF CLINICAL 1,300
AND PROPRIETARY INFORMATION; 1,301
(F) THE PERIODIC ASSESSMENT OF UTILIZATION REVIEW 1,303
ACTIVITIES, AND THE REPORTING OF THESE ASSESSMENTS TO THE HEALTH 1,304
INSURING CORPORATION'S BOARD, BY A UTILIZATION REVIEW COMMITTEE, 1,305
A QUALITY ASSURANCE COMMITTEE, OR ANY SIMILAR COMMITTEE; 1,306
(G) THE FUNCTIONAL RESPONSIBILITY FOR DAY-TO-DAY PROGRAM 1,309
MANAGEMENT BY STAFF;
(H) DEFINED METHODS BY WHICH GUIDELINES ARE APPROVED AND 1,311
COMMUNICATED TO PROVIDERS AND HEALTH CARE FACILITIES. 1,312
Sec. 1751.80. THE UTILIZATION REVIEW PROGRAM OF A HEALTH 1,314
INSURING CORPORATION SHALL BE IMPLEMENTED IN ACCORDANCE WITH ALL 1,315
OF THE FOLLOWING: 1,316
(A) THE PROGRAM SHALL USE DOCUMENTED CLINICAL REVIEW 1,319
CRITERIA THAT ARE BASED ON SOUND CLINICAL EVIDENCE AND ARE 1,320
EVALUATED PERIODICALLY TO ASSURE ONGOING EFFICACY. A HEALTH 1,321
INSURING CORPORATION MAY DEVELOP ITS OWN CLINICAL REVIEW CRITERIA 1,322
OR MAY PURCHASE OR LICENSE SUCH CRITERIA FROM QUALIFIED VENDORS. 1,323
A HEALTH INSURING CORPORATION SHALL MAKE ITS CLINICAL REVIEW 1,324
RATIONALE AVAILABLE UPON REQUEST TO AUTHORIZED GOVERNMENT
AGENCIES. THE RATIONALE MADE AVAILABLE TO AUTHORIZED GOVERNMENT 1,325
AGENCIES IS CONFIDENTIAL AND IS NOT A PUBLIC RECORD AS DEFINED IN 1,327
SECTION 149.43 OF THE REVISED CODE. 1,329
(B) QUALIFIED PROVIDERS SHALL ADMINISTER THE PROGRAM AND 1,332
30
OVERSEE REVIEW DETERMINATIONS. A CLINICAL PEER IN THE SAME, OR 1,334
IN A SIMILAR, SPECIALTY AS TYPICALLY MANAGES THE MEDICAL
CONDITION, PROCEDURE, OR TREATMENT UNDER REVIEW SHALL EVALUATE 1,335
THE CLINICAL APPROPRIATENESS OF ADVERSE DETERMINATIONS THAT ARE 1,336
THE SUBJECT OF AN APPEAL. 1,337
(C) THE HEALTH INSURING CORPORATION SHALL ISSUE 1,340
UTILIZATION REVIEW DETERMINATIONS IN A TIMELY MANNER PURSUANT TO 1,341
THE REQUIREMENTS OF SECTIONS 1751.81 AND 1751.82 OF THE REVISED 1,343
CODE AND THE ENROLLEE GRIEVANCE REQUIREMENTS. THE HEALTH 1,344
INSURING CORPORATION SHALL OBTAIN INFORMATION REQUIRED TO MAKE A 1,346
UTILIZATION REVIEW DETERMINATION, INCLUDING PERTINENT CLINICAL
INFORMATION, AND SHALL ESTABLISH A PROCESS TO ENSURE THAT 1,347
UTILIZATION REVIEWERS APPLY CLINICAL REVIEW CRITERIA 1,348
CONSISTENTLY. 1,349
(D) IF THE HEALTH INSURING CORPORATION DELEGATES ANY 1,352
UTILIZATION REVIEW ACTIVITIES TO A UTILIZATION REVIEW 1,353
ORGANIZATION, THE HEALTH INSURING CORPORATION SHALL MAINTAIN 1,354
ADEQUATE OVERSIGHT, INCLUDING A PROCESS BY WHICH THE HEALTH 1,355
INSURING CORPORATION EVALUATES THE PERFORMANCE OF THE 1,356
ORGANIZATION, AND SHALL MAINTAIN COPIES OF BOTH OF THE FOLLOWING: 1,358
(1) A WRITTEN DESCRIPTION OF THE ORGANIZATION'S ACTIVITIES 1,361
AND RESPONSIBILITIES, INCLUDING REPORTING REQUIREMENTS; 1,362
(2) EVIDENCE OF FORMAL APPROVAL OF THE ORGANIZATION'S 1,364
PROGRAM BY THE HEALTH INSURING CORPORATION. 1,365
(E) THE HEALTH INSURING CORPORATION OR ITS DESIGNEE 1,368
UTILIZATION REVIEW ORGANIZATION SHALL PROVIDE ENROLLEES AND 1,369
PARTICIPATING PROVIDERS WITH ACCESS TO ITS REVIEW STAFF BY MEANS 1,370
OF A TOLL-FREE TELEPHONE NUMBER OR COLLECT-CALL TELEPHONE LINE. 1,371
(F) WHEN CONDUCTING PROSPECTIVE OR CONCURRENT REVIEW, THE 1,374
HEALTH INSURING CORPORATION OR ITS DESIGNEE UTILIZATION REVIEW 1,375
ORGANIZATION SHALL COLLECT ONLY THE INFORMATION NECESSARY TO 1,376
CERTIFY THE ADMISSION, PROCEDURE OR TREATMENT, LENGTH OF STAY, 1,377
FREQUENCY, AND DURATION OF HEALTH CARE SERVICES. 1,378
(G) COMPENSATION TO PERSONS PROVIDING UTILIZATION REVIEW 1,381
31
SERVICES FOR THE HEALTH INSURING CORPORATION SHALL NOT CONTAIN 1,382
INCENTIVES, DIRECT OR INDIRECT, FOR THEM TO MAKE INAPPROPRIATE 1,383
REVIEW DECISIONS.
Sec. 1751.81. (A) AS USED IN THIS SECTION: 1,385
(1) "ENROLLEE" INCLUDES THE REPRESENTATIVE OF AN ENROLLEE. 1,387
(2) "NECESSARY INFORMATION" INCLUDES THE RESULTS OF ANY 1,389
FACE-TO-FACE CLINICAL EVALUATION OR SECOND OPINION THAT MAY BE 1,391
REQUIRED.
(B) A HEALTH INSURING CORPORATION SHALL MAINTAIN WRITTEN 1,393
PROCEDURES FOR MAKING UTILIZATION REVIEW DETERMINATIONS AND FOR 1,395
NOTIFYING ENROLLEES, AND PARTICIPATING PROVIDERS AND HEALTH CARE 1,397
FACILITIES ACTING ON BEHALF OF ENROLLEES, OF ITS DETERMINATIONS. 1,398
(C) FOR INITIAL DETERMINATIONS, A HEALTH INSURING 1,400
CORPORATION SHALL MAKE THE DETERMINATION WITHIN TWO BUSINESS DAYS 1,402
AFTER OBTAINING ALL NECESSARY INFORMATION REGARDING A PROPOSED 1,404
ADMISSION, PROCEDURE, OR HEALTH CARE SERVICE REQUIRING A REVIEW 1,405
DETERMINATION. 1,406
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN 1,408
ADMISSION, PROCEDURE, OR HEALTH CARE SERVICE, THE HEALTH INSURING 1,409
CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE FACILITY 1,410
RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN THREE 1,411
BUSINESS DAYS AFTER MAKING THE INITIAL CERTIFICATION, AND SHALL 1,413
PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE
NOTIFICATION TO THE ENROLLEE AND THE PROVIDER OR HEALTH CARE 1,414
FACILITY WITHIN TWO BUSINESS DAYS AFTER MAKING THE TELEPHONE 1,416
NOTIFICATION.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,418
INSURING CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE 1,420
FACILITY RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN 1,421
THREE BUSINESS DAYS AFTER MAKING THE ADVERSE DETERMINATION, AND 1,422
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE 1,423
NOTIFICATION TO THE ENROLLEE AND THE PROVIDER OR HEALTH CARE 1,424
FACILITY WITHIN ONE BUSINESS DAY AFTER MAKING THE TELEPHONE 1,425
NOTIFICATION.
32
(D) FOR CONCURRENT REVIEW DETERMINATIONS, A HEALTH 1,427
INSURING CORPORATION SHALL MAKE THE DETERMINATION WITHIN ONE 1,429
BUSINESS DAY AFTER OBTAINING ALL NECESSARY INFORMATION. 1,430
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN EXTENDED 1,432
STAY OR ADDITIONAL HEALTH CARE SERVICES, THE HEALTH INSURING 1,433
CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE FACILITY 1,434
RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN ONE 1,435
BUSINESS DAY AFTER MAKING THE CERTIFICATION, AND SHALL PROVIDE 1,437
WRITTEN OR ELECTRONIC CONFIRMATION TO THE ENROLLEE AND THE
PROVIDER OR HEALTH CARE FACILITY WITHIN ONE BUSINESS DAY AFTER 1,438
THE TELEPHONE NOTIFICATION. THE WRITTEN NOTIFICATION SHALL 1,439
INCLUDE THE NUMBER OF EXTENDED DAYS OR NEXT REVIEW DATE, THE NEW 1,440
TOTAL NUMBER OF DAYS OF HEALTH CARE SERVICES APPROVED, AND THE 1,442
DATE OF ADMISSION OR INITIATION OF HEALTH CARE SERVICES.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,444
INSURING CORPORATION SHALL NOTIFY THE PROVIDER OR HEALTH CARE 1,445
FACILITY RENDERING THE HEALTH CARE SERVICE BY TELEPHONE WITHIN 1,446
ONE BUSINESS DAY AFTER MAKING THE ADVERSE DETERMINATION, AND 1,447
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION TO THE ENROLLEE 1,448
AND THE PROVIDER OR HEALTH CARE FACILITY WITHIN ONE BUSINESS DAY 1,449
AFTER THE TELEPHONE NOTIFICATION. THE HEALTH CARE SERVICE TO THE 1,450
ENROLLEE SHALL BE CONTINUED, WITH STANDARD COPAYMENTS AND 1,452
DEDUCTIBLES, IF APPLICABLE, UNTIL THE ENROLLEE HAS BEEN NOTIFIED 1,453
OF THE DETERMINATION. 1,454
(E) FOR RETROSPECTIVE REVIEW DETERMINATIONS, A HEALTH 1,456
INSURING CORPORATION SHALL MAKE THE DETERMINATION WITHIN THIRTY 1,459
BUSINESS DAYS AFTER RECEIVING ALL NECESSARY INFORMATION. 1,460
(1) IN THE CASE OF A CERTIFICATION, THE HEALTH INSURING 1,462
CORPORATION MAY NOTIFY THE ENROLLEE AND THE PROVIDER OR HEALTH 1,464
CARE FACILITY RENDERING THE HEALTH CARE SERVICE IN WRITING. 1,465
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE HEALTH 1,467
INSURING CORPORATION SHALL NOTIFY THE ENROLLEE AND THE PROVIDER 1,469
OR HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE, IN 1,470
WRITING, WITHIN FIVE BUSINESS DAYS AFTER MAKING THE ADVERSE 1,471
33
DETERMINATION.
(F) THE TIME FRAMES SET FORTH IN DIVISIONS (C), (D), AND 1,474
(E) OF THIS SECTION FOR DETERMINATIONS AND NOTIFICATIONS SHALL 1,475
PREVAIL UNLESS THE SERIOUSNESS OF THE MEDICAL CONDITION OF THE 1,476
ENROLLEE OTHERWISE REQUIRES A MORE TIMELY RESPONSE FROM THE
HEALTH INSURING CORPORATION. THE HEALTH INSURING CORPORATION 1,477
SHALL MAINTAIN WRITTEN PROCEDURES FOR MAKING EXPEDITED 1,479
UTILIZATION REVIEW DETERMINATIONS AND NOTIFICATIONS OF ENROLLEES 1,480
AND PROVIDERS OR HEALTH CARE FACILITIES WHEN WARRANTED BY THE 1,481
MEDICAL CONDITION OF THE ENROLLEE. 1,482
(G) A WRITTEN NOTIFICATION OF AN ADVERSE DETERMINATION 1,484
SHALL INCLUDE THE PRINCIPAL REASON OR REASONS FOR THE 1,485
DETERMINATION, INSTRUCTIONS FOR INITIATING AN APPEAL OR 1,486
RECONSIDERATION OF THE DETERMINATION, AND INSTRUCTIONS FOR 1,487
REQUESTING A WRITTEN STATEMENT OF THE CLINICAL RATIONALE USED TO 1,488
MAKE THE DETERMINATION. A HEALTH INSURING CORPORATION SHALL
PROVIDE THE CLINICAL RATIONALE FOR AN ADVERSE DETERMINATION IN 1,490
WRITING TO ANY PARTY WHO RECEIVED NOTICE OF THE ADVERSE 1,492
DETERMINATION AND WHO FOLLOWS THE INSTRUCTIONS FOR A REQUEST. 1,493
(H) A HEALTH INSURING CORPORATION SHALL HAVE WRITTEN 1,495
PROCEDURES TO ADDRESS THE FAILURE OR INABILITY OF A HEALTH CARE 1,498
FACILITY, PROVIDER, OR ENROLLEE TO PROVIDE ALL NECESSARY 1,500
INFORMATION FOR REVIEW. IF THE HEALTH CARE FACILITY, PROVIDER,
OR ENROLLEE WILL NOT RELEASE NECESSARY INFORMATION, THE HEALTH 1,502
INSURING CORPORATION MAY DENY CERTIFICATION. 1,503
Sec. 1751.82. (A) IN A CASE INVOLVING AN INITIAL 1,506
DETERMINATION OR A CONCURRENT REVIEW DETERMINATION, A HEALTH 1,507
INSURING CORPORATION SHALL GIVE THE PROVIDER OR HEALTH CARE 1,508
FACILITY RENDERING THE HEALTH CARE SERVICE AN OPPORTUNITY TO 1,509
REQUEST IN WRITING ON BEHALF OF THE ENROLLEE A RECONSIDERATION OF 1,510
AN ADVERSE DETERMINATION BY THE REVIEWER MAKING THE ADVERSE 1,511
DETERMINATION. THE RECONSIDERATION SHALL OCCUR WITHIN THREE 1,512
BUSINESS DAYS AFTER THE HEALTH INSURING CORPORATION'S RECEIPT OF 1,513
THE WRITTEN REQUEST FOR RECONSIDERATION, AND SHALL BE CONDUCTED 1,514
34
BETWEEN THE PROVIDER OR HEALTH CARE FACILITY RENDERING THE HEALTH 1,515
CARE SERVICE AND THE REVIEWER WHO MADE THE ADVERSE DETERMINATION. 1,517
IF THAT REVIEWER CANNOT BE AVAILABLE WITHIN THREE BUSINESS DAYS, 1,518
THE REVIEWER MAY DESIGNATE ANOTHER REVIEWER.
(B) IF THE RECONSIDERATION PROCESS DESCRIBED IN DIVISION 1,521
(A) OF THIS SECTION DOES NOT RESOLVE THE DIFFERENCE OF OPINION, 1,522
THE ADVERSE DETERMINATION MAY BE APPEALED BY THE ENROLLEE OR THE 1,523
PROVIDER OR HEALTH CARE FACILITY ON BEHALF OF THE ENROLLEE. 1,524
(C) RECONSIDERATION IS NOT A PREREQUISITE TO A STANDARD OR 1,526
EXPEDITED APPEAL OF AN ADVERSE DETERMINATION. 1,527
(D) THE TIME PERIOD ALLOWED BY DIVISION (A) OF THIS 1,530
SECTION FOR A RECONSIDERATION OF AN ADVERSE DETERMINATION SHALL 1,531
NOT APPLY IF THE SERIOUSNESS OF THE MEDICAL CONDITION OF THE 1,532
ENROLLEE REQUIRES A MORE EXPEDITED RECONSIDERATION. THE HEALTH 1,533
INSURING CORPORATION SHALL MAINTAIN WRITTEN PROCEDURES FOR MAKING 1,534
SUCH AN EXPEDITED RECONSIDERATION. 1,535
Sec. 1751.83. A HEALTH INSURING CORPORATION MAY PRESENT 1,538
EVIDENCE OF COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1751.77 1,539
TO 1751.82 OF THE REVISED CODE BY SUBMITTING EVIDENCE TO THE 1,540
SUPERINTENDENT OF INSURANCE OF ITS ACCREDITATION BY AN
INDEPENDENT, PRIVATE ACCREDITING ORGANIZATION, SUCH AS THE 1,541
NATIONAL COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION ON 1,542
ACCREDITATION OF HEALTH CARE ORGANIZATIONS, OR THE AMERICAN 1,543
ACCREDITATION HEALTHCARE COMMISSION/UTILIZATION REVIEW 1,544
ACCREDITATION COMMISSION. THE SUPERINTENDENT, UPON REVIEW OF THE 1,546
ORGANIZATION'S ACCREDITATION PROCESS, MAY DETERMINE THAT SUCH 1,547
ACCREDITATION CONSTITUTES COMPLIANCE BY THE HEALTH INSURING
CORPORATION WITH THE REQUIREMENTS OF THESE SECTIONS. 1,548
Sec. 1751.84. EACH PARTICIPATING PROVIDER OR HEALTH CARE 1,550
FACILITY SUBMITTING A CLAIM SHALL COOPERATE WITH THE UTILIZATION 1,552
REVIEW PROGRAM OF A HEALTH INSURING CORPORATION OR UTILIZATION
REVIEW ORGANIZATION AND SHALL PROVIDE THE HEALTH INSURING 1,553
CORPORATION OR ITS DESIGNEE ACCESS TO AN ENROLLEE'S MEDICAL 1,554
RECORDS DURING REGULAR BUSINESS HOURS, OR COPIES OF THOSE RECORDS 1,555
35
AT A REASONABLE COST. 1,556
Sec. 1751.85. A HEALTH INSURING CORPORATION SHALL ANNUALLY 1,558
FILE A CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE 1,559
CERTIFYING ITS COMPLIANCE WITH SECTIONS 1751.77 TO 1751.82 OF THE 1,560
REVISED CODE. 1,562
Sec. 1751.86. (A) NO HEALTH INSURING CORPORATION SHALL 1,565
FAIL TO COMPLY WITH SECTIONS 1751.77 TO 1751.82 OF THE REVISED 1,566
CODE.
(B) WHOEVER VIOLATES DIVISION (A) OF THIS SECTION IS 1,569
DEEMED TO HAVE ENGAGED IN AN UNFAIR AND DECEPTIVE ACT OR PRACTICE 1,571
IN THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 TO 3901.26 OF 1,572
THE REVISED CODE.
Sec. 1753.01. AS USED IN THIS CHAPTER: 1,574
(A) "ECONOMIC PROFILING" MEANS A HEALTH INSURING 1,576
CORPORATION'S USE OF ECONOMIC PERFORMANCE DATA AND ECONOMIC 1,577
INFORMATION IN DETERMINING WHETHER TO CONTRACT WITH A PROVIDER 1,578
FOR THE PROVISION OF COVERED HEALTH CARE SERVICES TO ENROLLEES AS 1,580
A PARTICIPATING PROVIDER.
(B) "BASIC HEALTH CARE SERVICES," "ENROLLEE," "HEALTH CARE 1,582
FACILITY," "HEALTH CARE SERVICES," "HEALTH INSURING CORPORATION," 1,583
"MEDICAL RECORD," "PROVIDER," AND "SUPPLEMENTAL HEALTH CARE 1,584
SERVICES" HAVE THE SAME MEANINGS AS IN SECTION 1751.01 OF THE 1,586
REVISED CODE.
Sec. 1753.03. THE SUPERINTENDENT OF INSURANCE SHALL 1,588
PRESCRIBE A STANDARD CREDENTIALING FORM TO BE USED BY ALL HEALTH 1,589
INSURING CORPORATIONS WHEN CREDENTIALING PROVIDERS IN CONNECTION 1,590
WITH POLICIES, CONTRACTS, AND AGREEMENTS PROVIDING BASIC HEALTH 1,591
CARE SERVICES. THE DIRECTOR OF HEALTH MAY MAKE RECOMMENDATIONS 1,592
TO THE SUPERINTENDENT FOR SUCH A STANDARD CREDENTIALING FORM. IF 1,593
THE DIRECTOR MAKES SUCH RECOMMENDATIONS, THE DIRECTOR SHALL TAKE 1,594
INTO CONSIDERATION THE STANDARD CREDENTIALING FORMS DEVELOPED BY 1,595
THE NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS, THE AMERICAN 1,597
MEDICAL ASSOCIATION, THE AMERICAN ASSOCIATION OF HEALTH PLANS, 1,599
AND ANY OTHER NATIONAL ORGANIZATION THAT HAS DEVELOPED SUCH A 1,600
36
FORM. IN PRESCRIBING A STANDARD CREDENTIALING FORM, THE 1,601
SUPERINTENDENT SHALL CONSIDER ANY RECOMMENDATIONS MADE BY THE 1,602
DIRECTOR. THE SUPERINTENDENT MAY AMEND OR REVISE THE PRESCRIBED 1,603
STANDARD CREDENTIALING FORM AS NECESSARY.
Sec. 1753.04. BEGINNING ONE HUNDRED TWENTY DAYS AFTER THE 1,605
SUPERINTENDENT OF INSURANCE PRESCRIBES A STANDARD CREDENTIALING 1,606
FORM UNDER SECTION 1753.03 OF THE REVISED CODE, NO HEALTH 1,609
INSURING CORPORATION SHALL FAIL TO USE THE PRESCRIBED STANDARD 1,610
CREDENTIALING FORM WHEN INITIALLY CREDENTIALING OR 1,611
RECREDENTIALING PROVIDERS IN CONNECTION WITH POLICIES, CONTRACTS, 1,612
AND AGREEMENTS PROVIDING BASIC HEALTH CARE SERVICES. IF THE 1,613
SUPERINTENDENT AMENDS OR REVISES THE STANDARD CREDENTIALING FORM, 1,615
A HEALTH INSURING CORPORATION SHALL USE THE AMENDED OR REVISED 1,616
FORM TO CREDENTIAL OR RECREDENTIAL PROVIDERS. 1,617
A HEALTH INSURING CORPORATION MAY REQUEST SUCH INFORMATION 1,620
FROM A PROVIDER, IN ADDITION TO THAT INFORMATION TO BE PROVIDED
ON THE STANDARD CREDENTIALING FORM, AS NECESSITATED BY THE HEALTH 1,622
INSURING CORPORATION'S CREDENTIALING STANDARDS.
Sec. 1753.05. (A) A HEALTH INSURING CORPORATION MAY USE 1,625
ECONOMIC PROFILING AS A FACTOR IN CREDENTIALING A PROVIDER, 1,626
HOWEVER, SUCH ECONOMIC PROFILING SHALL TAKE INTO CONSIDERATION 1,627
THE CASE MIX, SEVERITY OF ILLNESS, AND AGE OF PATIENTS. 1,628
(B) FOR AN INITIAL APPLICANT, A HEALTH INSURING 1,630
CORPORATION MAY REQUEST INFORMATION NECESSARY TO PERFORM AN 1,631
ECONOMIC PROFILE. IF INFORMATION ON CASE MIX, SEVERITY OF 1,632
ILLNESS, AND AGE OF PATIENTS IS REQUESTED BY A HEALTH INSURING 1,633
CORPORATION AND NOT PRODUCED BY THE APPLICANT, THE HEALTH 1,634
INSURING CORPORATION IS NOT REQUIRED TO TAKE THESE FACTORS INTO 1,635
CONSIDERATION IN ITS ECONOMIC PROFILE OF THE PROVIDER. 1,636
(C) NOTHING IN THIS SECTION PROHIBITS A HEALTH INSURING 1,639
CORPORATION FROM TAKING INTO CONSIDERATION THE QUALITY AND 1,640
APPROPRIATENESS OF CARE PROVIDED BY A PROVIDER WHEN DECIDING
WHETHER TO EMPLOY, CONTRACT WITH, OR TERMINATE THE PROVIDER. 1,642
Sec. 1753.06. A HEALTH INSURING CORPORATION SHALL NOTIFY A 1,645
37
PROVIDER SEEKING TO ENTER INTO A PARTICIPATION CONTRACT WITH THE
HEALTH INSURING CORPORATION OF THE STATUS OF THE PROVIDER'S 1,646
APPLICATION WITHIN ONE HUNDRED TWENTY DAYS AFTER THE HEALTH 1,647
INSURING CORPORATION'S RECEIPT OF THE PROVIDER'S COMPLETED 1,648
APPLICATION. THAT TIME PERIOD MAY BE EXTENDED BY A HEALTH 1,649
INSURING CORPORATION IF, DUE TO EXTENUATING CIRCUMSTANCES, THE 1,650
HEALTH INSURING CORPORATION NEEDS ADDITIONAL TIME TO CONSIDER THE 1,651
APPLICATION AND NOTIFIES THE PROVIDER OF THE REASON FOR THE 1,652
DELAY.
Sec. 1753.07. (A) PRIOR TO ENTERING INTO A PARTICIPATION 1,655
CONTRACT WITH A PROVIDER UNDER SECTION 1751.13 OF THE REVISED 1,656
CODE, A HEALTH INSURING CORPORATION SHALL DISCLOSE BASIC 1,657
INFORMATION REGARDING ITS PROGRAMS AND PROCEDURES TO THE 1,658
PROVIDER, UPON THE PROVIDER'S REQUEST. THE INFORMATION SHALL 1,659
INCLUDE ALL OF THE FOLLOWING:
(1) HOW A PARTICIPATING PROVIDER IS REIMBURSED FOR THE 1,661
PARTICIPATING PROVIDER'S SERVICES, INCLUDING THE RANGE AND 1,663
STRUCTURE OF ANY FINANCIAL RISK SHARING ARRANGEMENTS, A 1,664
DESCRIPTION OF ANY INCENTIVE PLANS, AND, IF REIMBURSED ACCORDING 1,665
TO A TYPE OF FEE-FOR-SERVICE ARRANGEMENT, THE LEVEL OF 1,666
REIMBURSEMENT FOR THE PARTICIPATING PROVIDER'S SERVICES; 1,667
(2) HOW REFERRALS TO OTHER PARTICIPATING PROVIDERS OR TO 1,669
NONPARTICIPATING PROVIDERS ARE MADE; 1,670
(3) THE AVAILABILITY OF DISPUTE RESOLUTION PROCEDURES AND 1,672
THE POTENTIAL FOR COST TO BE INCURRED; 1,673
(4) HOW A PARTICIPATING PROVIDER'S NAME AND ADDRESS WILL 1,675
BE USED IN MARKETING MATERIALS. 1,676
(B) A HEALTH INSURING CORPORATION SHALL PROVIDE ALL OF THE 1,679
FOLLOWING TO A PARTICIPATING PROVIDER:
(1) ANY MATERIAL INCORPORATED BY REFERENCE INTO THE 1,681
PARTICIPATION CONTRACT, THAT IS NOT OTHERWISE AVAILABLE AS A 1,682
PUBLIC RECORD, IF SUCH MATERIAL AFFECTS THE PARTICIPATING 1,683
PROVIDER;
(2) ADMINISTRATIVE MANUALS RELATED TO PROVIDER 1,685
38
PARTICIPATION, IF ANY; 1,686
(3) A SIGNED AND DATED COPY OF THE FINAL PARTICIPATION 1,688
CONTRACT. 1,689
Sec. 1753.08. (A) A HEALTH INSURING CORPORATION SHALL 1,691
NOTIFY A PARTICIPATING PROVIDER PRIOR TO THE EFFECTIVE DATE OF AN 1,693
AMENDMENT TO THE PARTICIPATING PROVIDER'S CONTRACT WITH THE 1,695
HEALTH INSURING CORPORATION, AND PRIOR TO THE EFFECTIVE DATE OF
AN AMENDMENT TO ANY DOCUMENT INCORPORATED BY REFERENCE INTO THE 1,697
CONTRACT IF THE AMENDMENT OF THE DOCUMENT DIRECTLY AND MATERIALLY 1,698
AFFECTS THE PARTICIPATING PROVIDER. SUCH AMENDMENTS SHALL NOT BE 1,700
EFFECTIVE WITH REGARD TO A PARTICIPATING PROVIDER UNTIL THE 1,701
PARTICIPATING PROVIDER HAS HAD REASONABLE TIME, AS DEFINED IN THE 1,702
CONTRACT, TO EXERCISE THE PARTICIPATING PROVIDER'S RIGHT TO 1,703
TERMINATE ITS PARTICIPATION STATUS IN ACCORDANCE WITH THE TERMS 1,704
AND CONDITIONS OF THE CONTRACT. 1,705
(B) DIVISION (A) OF THIS SECTION DOES NOT APPLY IF THE 1,708
DELAY CAUSED BY COMPLIANCE WITH THAT DIVISION COULD RESULT IN 1,709
IMMINENT HARM TO AN ENROLLEE OR IF THE AMENDMENT IS REQUIRED BY 1,710
STATE OR FEDERAL LAW, RULE, OR REGULATION. 1,711
Sec. 1753.09. (A) EXCEPT AS PROVIDED IN DIVISION (D) OF 1,714
THIS SECTION, PRIOR TO TERMINATING THE PARTICIPATION OF A 1,715
PROVIDER ON THE BASIS OF THE PARTICIPATING PROVIDER'S FAILURE TO 1,716
MEET THE HEALTH INSURING CORPORATION'S STANDARDS FOR QUALITY OR 1,717
UTILIZATION IN THE DELIVERY OF HEALTH CARE SERVICES, A HEALTH 1,719
INSURING CORPORATION SHALL GIVE THE PARTICIPATING PROVIDER NOTICE 1,720
OF THE REASON OR REASONS FOR ITS DECISION TO TERMINATE THE 1,721
PROVIDER'S PARTICIPATION AND AN OPPORTUNITY TO TAKE CORRECTIVE 1,722
ACTION. THE HEALTH INSURING CORPORATION SHALL DEVELOP A 1,723
PERFORMANCE IMPROVEMENT PLAN IN CONJUNCTION WITH THE
PARTICIPATING PROVIDER. IF AFTER BEING AFFORDED THE OPPORTUNITY 1,724
TO COMPLY WITH THE PERFORMANCE IMPROVEMENT PLAN, THE 1,725
PARTICIPATING PROVIDER FAILS TO DO SO, THE HEALTH INSURING 1,726
CORPORATION MAY TERMINATE THE PARTICIPATION OF THE PROVIDER. 1,727
(B)(1) A PARTICIPATING PROVIDER WHOSE PARTICIPATION HAS 1,729
39
BEEN TERMINATED UNDER DIVISION (A) OF THIS SECTION MAY APPEAL THE 1,732
TERMINATION TO THE APPROPRIATE MEDICAL DIRECTOR OF THE HEALTH 1,733
INSURING CORPORATION. THE MEDICAL DIRECTOR SHALL GIVE THE 1,734
PARTICIPATING PROVIDER AN OPPORTUNITY TO DISCUSS WITH THE MEDICAL 1,735
DIRECTOR THE REASON OR REASONS FOR THE TERMINATION.
(2) IF A SATISFACTORY RESOLUTION OF A PARTICIPATING 1,737
PROVIDER'S APPEAL CANNOT BE REACHED UNDER DIVISION (B)(1) OF THIS 1,739
SECTION, THE PARTICIPATING PROVIDER MAY APPEAL THE TERMINATION TO 1,740
A PANEL COMPOSED OF PARTICIPATING PROVIDERS WHO HAVE COMPARABLE 1,742
OR HIGHER LEVELS OF EDUCATION AND TRAINING THAN THE PARTICIPATING 1,743
PROVIDER MAKING THE APPEAL. A REPRESENTATIVE OF THE 1,744
PARTICIPATING PROVIDER'S SPECIALTY SHALL BE A MEMBER OF THE 1,745
PANEL, IF POSSIBLE. THIS PANEL SHALL HOLD A HEARING, AND SHALL 1,746
RENDER ITS RECOMMENDATION IN THE APPEAL WITHIN THIRTY DAYS AFTER 1,747
HOLDING THE HEARING. THE RECOMMENDATION SHALL BE PRESENTED TO 1,748
THE MEDICAL DIRECTOR AND TO THE PARTICIPATING PROVIDER. 1,749
(3) THE MEDICAL DIRECTOR SHALL REVIEW AND CONSIDER THE 1,751
PANEL'S RECOMMENDATION BEFORE MAKING A DECISION. THE DECISION 1,752
RENDERED BY THE MEDICAL DIRECTOR SHALL BE FINAL. 1,753
(C) A PROVIDER'S STATUS AS A PARTICIPATING PROVIDER SHALL 1,756
REMAIN IN EFFECT DURING THE APPEAL PROCESS SET FORTH IN DIVISION 1,758
(B) OF THIS SECTION UNLESS THE TERMINATION WAS BASED ON ANY OF 1,759
THE REASONS LISTED IN DIVISION (D) OF THIS SECTION. 1,761
(D) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A 1,763
PROVIDER'S PARTICIPATION MAY BE IMMEDIATELY TERMINATED IF THE 1,765
PARTICIPATING PROVIDER'S CONDUCT PRESENTS AN IMMINENT RISK OF 1,766
HARM TO AN ENROLLEE OR ENROLLEES; OR IF THERE HAS OCCURRED 1,767
UNACCEPTABLE QUALITY OF CARE, FRAUD, PATIENT ABUSE, LOSS OF 1,768
CLINICAL PRIVILEGES, LOSS OF PROFESSIONAL LIABILITY COVERAGE, 1,769
INCOMPETENCE, OR LOSS OF AUTHORITY TO PRACTICE IN THE 1,770
PARTICIPATING PROVIDER'S FIELD; OR IF A GOVERNMENTAL ACTION HAS 1,771
IMPAIRED THE PARTICIPATING PROVIDER'S ABILITY TO PRACTICE. 1,772
(E) DIVISIONS (A) TO (D) OF THIS SECTION APPLY ONLY TO 1,775
PROVIDERS WHO ARE NATURAL PERSONS.
40
(F)(1) NOTHING IN THIS SECTION PROHIBITS A HEALTH INSURING 1,778
CORPORATION FROM REJECTING A PROVIDER'S APPLICATION FOR 1,779
PARTICIPATION, OR FROM TERMINATING A PARTICIPATING PROVIDER'S 1,780
CONTRACT, IF THE HEALTH INSURING CORPORATION DETERMINES THAT THE 1,781
HEALTH CARE NEEDS OF ITS ENROLLEES ARE BEING MET AND NO NEED 1,782
EXISTS FOR THE PROVIDER'S OR PARTICIPATING PROVIDER'S SERVICES. 1,783
(2) NOTHING IN THIS SECTION SHALL BE CONSTRUED AS 1,785
PROHIBITING A HEALTH INSURING CORPORATION FROM TERMINATING A 1,786
PARTICIPATING PROVIDER WHO DOES NOT MEET THE TERMS AND CONDITIONS 1,788
OF THE PARTICIPATING PROVIDER'S CONTRACT.
(G) THE SUPERINTENDENT OF INSURANCE MAY ADOPT RULES AS 1,791
NECESSARY TO IMPLEMENT AND ENFORCE SECTIONS 1753.04 TO 1753.09 OF 1,792
THE REVISED CODE. SUCH RULES SHALL BE ADOPTED IN ACCORDANCE WITH 1,794
CHAPTER 119. OF THE REVISED CODE. THE DIRECTOR OF HEALTH MAY 1,798
MAKE RECOMMENDATIONS TO THE SUPERINTENDENT FOR RULES NECESSARY TO 1,799
IMPLEMENT AND ENFORCE SECTIONS 1753.04 TO 1753.09 OF THE REVISED 1,800
CODE. IN ADOPTING ANY RULES PURSUANT TO THIS DIVISION, THE 1,802
SUPERINTENDENT SHALL CONSIDER THE RECOMMENDATIONS OF THE 1,803
DIRECTOR.
Sec. 1753.10. NOTHING IN THIS CHAPTER OR CHAPTER 1751. OF 1,806
THE REVISED CODE REQUIRES A HEALTH INSURING CORPORATION TO EMPLOY 1,809
OR CONTRACT WITH, OR PROHIBITS A HEALTH INSURING CORPORATION FROM 1,810
EMPLOYING OR CONTRACTING WITH, ANY CATEGORY OF PROVIDER FOR THE 1,811
PROVISION OF BASIC OR SUPPLEMENTAL HEALTH CARE SERVICES, WHICH 1,812
HEALTH CARE SERVICES ARE WITHIN THE RECOGNIZED SCOPE OF PRACTICE 1,813
OF THAT CATEGORY OF PROVIDER. 1,814
Sec. 1753.14. (A) A HEALTH INSURING CORPORATION THAT DOES 1,817
NOT ALLOW DIRECT ACCESS TO ALL SPECIALISTS SHALL ESTABLISH AND 1,818
IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE MAY RECEIVE A STANDING 1,819
REFERRAL TO A SPECIALIST. THE PROCEDURE SHALL PROVIDE FOR A 1,820
STANDING REFERRAL TO A SPECIALIST IF A PRIMARY CARE PROVIDER 1,821
DETERMINES IN CONSULTATION WITH A SPECIALIST THAT AN ENROLLEE 1,822
NEEDS CONTINUING CARE FROM A SPECIALIST. THE REFERRAL SHALL BE 1,823
MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE HEALTH INSURING 1,824
41
CORPORATION IN CONSULTATION WITH THE PRIMARY CARE PROVIDER, A 1,825
SPECIALIST, AND THE ENROLLEE. THE TREATMENT PLAN MAY LIMIT THE 1,826
NUMBER OF VISITS TO THE SPECIALIST, LIMIT THE PERIOD OF TIME THAT 1,827
THE VISITS ARE AUTHORIZED, OR REQUIRE THAT THE SPECIALIST PROVIDE 1,828
THE PRIMARY CARE PROVIDER WITH REGULAR REPORTS ON THE HEALTH CARE 1,830
PROVIDED TO THE ENROLLEE.
(B) A HEALTH INSURING CORPORATION SHALL ESTABLISH AND 1,833
IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE WITH A CONDITION OR 1,834
DISEASE THAT REQUIRES SPECIALIZED MEDICAL CARE OVER A PROLONGED 1,835
PERIOD OF TIME AND IS LIFE-THREATENING, DEGENERATIVE, OR 1,836
DISABLING MAY RECEIVE A REFERRAL TO A SPECIALIST WHO HAS 1,837
EXPERTISE IN TREATING THE CONDITION OR DISEASE FOR THE PURPOSE OF 1,838
HAVING THE SPECIALIST COORDINATE THE ENROLLEE'S HEALTH CARE. THE 1,840
PROCEDURE SHALL PROVIDE FOR SUCH A REFERRAL IF A PRIMARY CARE 1,841
PROVIDER DETERMINES IN CONSULTATION WITH THE SPECIALIST THAT THE 1,842
ENROLLEE NEEDS THE SPECIALIST'S EXPERTISE. THE REFERRAL SHALL BE 1,844
MADE PURSUANT TO A TREATMENT PLAN APPROVED BY THE HEALTH INSURING 1,846
CORPORATION IN CONSULTATION WITH THE PRIMARY CARE PROVIDER, THE 1,847
SPECIALIST, AND THE ENROLLEE. AFTER THE REFERRAL IS MADE, THE 1,848
SPECIALIST IS AUTHORIZED TO PROVIDE HEALTH CARE SERVICES TO THE 1,849
ENROLLEE IN THE SAME MANNER AS THE ENROLLEE'S PRIMARY CARE 1,850
PROVIDER, SUBJECT TO THE TERMS OF THE TREATMENT PLAN. 1,851
(C) THE DETERMINATIONS DESCRIBED IN DIVISIONS (A) AND (B) 1,855
OF THIS SECTION SHALL BE MADE WITHIN THREE BUSINESS DAYS AFTER A 1,856
REQUEST FOR THE DETERMINATION IS MADE BY THE ENROLLEE OR THE 1,857
ENROLLEE'S PRIMARY CARE PROVIDER AND ALL APPROPRIATE MEDICAL 1,858
RECORDS AND OTHER ITEMS OF INFORMATION NECESSARY TO MAKE THE 1,859
DETERMINATION HAVE BEEN PROVIDED. 1,860
(D) ONCE A DETERMINATION IN FAVOR OF A REFERRAL IS MADE, 1,862
THE REFERRAL SHALL BE MADE WITHIN FOUR BUSINESS DAYS AFTER THE 1,864
DETERMINATION. THIS TIME PERIOD DOES NOT APPLY TO STANDING 1,865
REFERRALS INVOLVING A RARE OR UNUSUAL CONDITION FOR WHICH 1,866
APPROPRIATE SPECIALISTS ARE LIMITED IN NUMBER OR OTHERWISE 1,867
DIFFICULT TO IDENTIFY. 1,868
42
DIVISIONS (A) AND (B) OF THIS SECTION DO NOT REQUIRE A 1,872
HEALTH INSURING CORPORATION TO PERMIT AN ENROLLEE TO ELECT 1,873
REFERRAL TO A SPECIALIST WHO IS NOT EMPLOYED BY OR UNDER CONTRACT 1,874
WITH THE HEALTH INSURING CORPORATION FOR THE PROVISION OF HEALTH 1,875
CARE SERVICES TO THE HEALTH INSURING CORPORATION'S ENROLLEES. 1,876
Sec. 1753.16. A HEALTH INSURING CORPORATION OR UTILIZATION 1,879
REVIEW ORGANIZATION THAT AUTHORIZES A PROPOSED ADMISSION, 1,880
TREATMENT, OR HEALTH CARE SERVICE BY A PARTICIPATING PROVIDER
BASED UPON THE COMPLETE AND ACCURATE SUBMISSION OF ALL NECESSARY 1,881
INFORMATION RELATIVE TO AN ELIGIBLE ENROLLEE SHALL NOT 1,882
RETROACTIVELY DENY THIS AUTHORIZATION IF THE PROVIDER RENDERS THE 1,883
HEALTH CARE SERVICE IN GOOD FAITH AND PURSUANT TO THE 1,884
AUTHORIZATION AND ALL OF THE TERMS AND CONDITIONS OF THE 1,885
PROVIDER'S CONTRACT WITH THE HEALTH INSURING CORPORATION. 1,886
Sec. 1753.21. (A) IF A POLICY, CONTRACT, OR AGREEMENT OF 1,888
A HEALTH INSURING CORPORATION USES A RESTRICTED FORMULARY OF 1,891
PRESCRIPTION DRUGS, THE HEALTH INSURING CORPORATION SHALL DO BOTH 1,892
OF THE FOLLOWING:
(1) DEVELOP SUCH A FORMULARY IN CONSULTATION WITH AND WITH 1,895
THE APPROVAL OF A PHARMACY AND THERAPEUTICS COMMITTEE, A MAJORITY 1,896
OF THE MEMBERS OF WHICH ARE PHYSICIANS AFFILIATED WITH THE HEALTH 1,897
INSURING CORPORATION WHO MAY PRESCRIBE PRESCRIPTION DRUGS AND 1,898
PHARMACISTS AFFILIATED WITH THE HEALTH INSURING CORPORATION; OR 1,899
IN CONSULTATION WITH AND WITH THE APPROVAL OF A PHARMACY AND 1,900
THERAPEUTICS COMMITTEE THAT IS INDEPENDENT OF THE HEALTH INSURING 1,901
CORPORATION CONSISTING OF PHYSICIANS WHO MAY PRESCRIBE 1,902
PRESCRIPTION DRUGS IN THEIR STATE OF LICENSURE AND PHARMACISTS 1,903
WHO ARE AUTHORIZED TO PRACTICE IN THEIR STATE OF LICENSURE; 1,905
(2) ESTABLISH A PROCEDURE BY WHICH AN ENROLLEE MAY OBTAIN, 1,908
WITHOUT PENALTY OR ADDITIONAL COST SHARING BEYOND THAT PROVIDED 1,909
FOR FORMULARY DRUGS UNDER THE ENROLLEE'S CONTRACT WITH THE HEALTH 1,910
INSURING CORPORATION, COVERAGE OF A SPECIFIC NONFORMULARY DRUG 1,911
WHEN THE PRESCRIBER DOCUMENTS IN THE ENROLLEE'S MEDICAL RECORD 1,912
AND CERTIFIES THAT THE FORMULARY ALTERNATIVE HAS BEEN INEFFECTIVE 1,913
43
IN THE TREATMENT OF THE ENROLLEE'S DISEASE OR CONDITION, OR THAT 1,914
THE FORMULARY ALTERNATIVE CAUSES OR IS REASONABLY EXPECTED BY THE 1,915
PRESCRIBER TO CAUSE A HARMFUL OR ADVERSE REACTION IN THE 1,916
ENROLLEE.
(B) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE 1,919
A HEALTH INSURING CORPORATION TO PLACE ANY PARTICULAR 1,920
PHARMACEUTICAL PRODUCT OR THERAPEUTIC CLASS OF PRODUCT ON ANY 1,921
FORMULARY, OR TO PROHIBIT A HEALTH INSURING CORPORATION FROM 1,922
RESTRICTING PAYMENTS FOR ANY SPECIFIC PHARMACEUTICAL PRODUCT OR 1,923
THERAPEUTIC CLASS OF PRODUCT, INCLUDING, BUT NOT LIMITED TO, A 1,924
REQUIREMENT THAT THE PRODUCT BE PRESCRIBED ONLY BY A DEFINED 1,925
SPECIALIST OR SUBSPECIALIST.
Sec. 1753.23. A HEALTH INSURING CORPORATION SHALL 1,928
ESTABLISH OR USE AN INTERNAL TECHNOLOGY ASSESSMENT PROCESS FOR
ASSESSING WHETHER A DRUG, DEVICE, PROTOCOL, PROCEDURE, OR OTHER 1,929
THERAPY IS PROVEN TO BE SAFE AND EFFICACIOUS FOR A PARTICULAR 1,930
INDICATION OR CONDITION WHEN COMPARED TO ALTERNATIVE THERAPIES, 1,931
OR WHETHER IT REMAINS EXPERIMENTAL OR INVESTIGATIONAL. THE 1,932
HEALTH INSURING CORPORATION'S INTERNAL TECHNOLOGY ASSESSMENT 1,933
PROCESS SHALL MEET ALL OF THE FOLLOWING CRITERIA: 1,934
(A) DECISIONS ARE MADE BY MEDICAL PROFESSIONALS, INCLUDING 1,937
PHYSICIANS.
(B) THE PROCESS INCLUDES A REVIEW OF RELEVANT MEDICAL 1,940
EVIDENCE, INCLUDING THE FOLLOWING, IF AVAILABLE: 1,941
(1) PEER-REVIEWED MEDICAL AND SCIENTIFIC LITERATURE ON THE 1,944
SUBJECT;
(2) PUBLISHED OPINIONS, ACTIONS, AND OTHER RELEVANT 1,946
DOCUMENTS OF INDEPENDENT, EXTERNAL RESEARCH ORGANIZATIONS SUCH AS 1,948
THE NATIONAL INSTITUTE OF HEALTH, THE NATIONAL CANCER INSTITUTE, 1,949
THE UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 1,951
FINANCE ADMINISTRATION, AND THE AGENCY FOR HEALTH CARE POLICY AND 1,952
RESEARCH; 1,953
(3) PUBLISHED OPINIONS OF MEDICAL EXPERTS OR AFFECTED 1,955
SPECIALTY SOCIETIES. 1,956
44
(C) GENERAL COVERAGE DECISIONS, MADE PURSUANT TO THIS 1,959
PROCESS, THAT EXCLUDE DRUGS, DEVICES, PROTOCOLS, PROCEDURES, OR 1,960
OTHER THERAPIES ON THE BASIS THAT THEY ARE NOT SAFE OR 1,961
EFFICACIOUS AND REMAIN EXPERIMENTAL OR INVESTIGATIONAL, ARE 1,962
REVIEWED AND UPDATED AS NEW SCIENTIFIC EVIDENCE BECOMES 1,963
AVAILABLE.
(D) A DESCRIPTION OF THE HEALTH INSURING CORPORATION'S 1,966
INTERNAL TECHNOLOGY ASSESSMENT PROCESS IS MADE AVAILABLE TO 1,967
PARTICIPATING PROVIDERS AND ENROLLEES, UPON REQUEST. 1,968
(E) A COPY OF THE HEALTH INSURING CORPORATION'S SPECIFIC 1,971
COVERAGE PROTOCOLS AND PROCEDURES IS MADE AVAILABLE TO 1,972
PARTICIPATING PROVIDERS AND ENROLLEES UPON THE REQUEST OF AN 1,973
ENROLLEE WHO HAS BEEN DENIED COVERAGE FOR A DRUG, DEVICE, 1,974
PROTOCOL, PROCEDURE, OR OTHER THERAPY ON THE BASIS THAT IT HAS 1,975
BEEN ASSESSED AS NOT BEING SAFE OR EFFICACIOUS FOR A PARTICULAR 1,976
INDICATION OR CONDITION. SPECIFIC COVERAGE PROTOCOLS AND 1,977
PROCEDURES SHALL INCLUDE A DESCRIPTION OF THE EVIDENCE UPON WHICH 1,978
THE PROTOCOL OR PROCEDURE IS BASED, AND SHALL CONTAIN THE DATE 1,979
THE PROTOCOL OR PROCEDURE WAS ADOPTED. 1,980
Sec. 1753.24. (A) EACH HEALTH INSURING CORPORATION SHALL 1,982
ESTABLISH A REASONABLE EXTERNAL, INDEPENDENT REVIEW PROCESS TO 1,984
EXAMINE THE HEALTH INSURING CORPORATION'S COVERAGE DECISIONS FOR 1,986
ENROLLEES WHO MEET ALL OF THE FOLLOWING CRITERIA:
(1) THE ENROLLEE HAS A TERMINAL CONDITION THAT, ACCORDING 1,988
TO THE CURRENT DIAGNOSIS OF THE ENROLLEE'S PHYSICIAN, HAS A HIGH 1,989
PROBABILITY OF CAUSING DEATH WITHIN TWO YEARS. 1,990
(2) THE ENROLLEE'S PHYSICIAN CERTIFIES THAT THE ENROLLEE 1,992
HAS THE CONDITION DESCRIBED IN DIVISION (A)(1) OF THIS SECTION 1,993
AND ANY OF THE FOLLOWING SITUATIONS ARE APPLICABLE: 1,994
(a) STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN 1,996
IMPROVING THE CONDITION OF THE ENROLLEE; 1,998
(b) STANDARD THERAPIES ARE NOT MEDICALLY APPROPRIATE FOR 2,001
THE ENROLLEE;
(c) THERE IS NO STANDARD THERAPY COVERED BY THE HEALTH 2,004
45
INSURING CORPORATION THAT IS MORE BENEFICIAL THAN THERAPY 2,005
DESCRIBED IN DIVISION (A)(3) OF THIS SECTION. 2,006
(3) THE ENROLLEE'S PHYSICIAN HAS RECOMMENDED A DRUG, 2,008
DEVICE, PROCEDURE, OR OTHER THERAPY THAT THE PHYSICIAN CERTIFIES, 2,009
IN WRITING, IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE, IN 2,010
THE PHYSICIAN'S OPINION, THAN STANDARD THERAPIES, OR, THE 2,012
ENROLLEE HAS REQUESTED A THERAPY THAT HAS BEEN FOUND IN A
PREPONDERANCE OF PEER-REVIEWED PUBLISHED STUDIES TO BE ASSOCIATED 2,013
WITH EFFECTIVE CLINICAL OUTCOMES FOR THE SAME CONDITION. 2,014
(4) THE ENROLLEE HAS BEEN DENIED COVERAGE BY THE HEALTH 2,016
INSURING CORPORATION FOR A DRUG, DEVICE, PROCEDURE, OR OTHER 2,019
THERAPY RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF 2,020
THIS SECTION, AND HAS EXHAUSTED ALL INTERNAL APPEALS.
(5) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, 2,022
RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF THIS 2,024
SECTION, WOULD BE A COVERED HEALTH CARE SERVICE EXCEPT FOR THE 2,026
HEALTH INSURING CORPORATION'S DETERMINATION THAT THE DRUG,
DEVICE, PROCEDURE, OR OTHER THERAPY IS EXPERIMENTAL OR 2,028
INVESTIGATIONAL.
(B) THE EXTERNAL, INDEPENDENT REVIEW PROCESS ESTABLISHED 2,030
BY A HEALTH INSURING CORPORATION SHALL MEET ALL OF THE FOLLOWING 2,031
CRITERIA:
(1) EXCEPT AS PROVIDED IN DIVISION (C) OF THIS SECTION, 2,033
THE PROCESS SHALL OFFER ALL ENROLLEES WHO MEET THE CRITERIA SET 2,034
FORTH IN DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE THE 2,036
HEALTH INSURING CORPORATION'S DECISION TO DENY COVERAGE OF THE 2,037
RECOMMENDED OR REQUESTED THERAPY REVIEWED UNDER THE PROCESS. 2,038
EACH ELIGIBLE ENROLLEE SHALL BE NOTIFIED OF THAT OPPORTUNITY 2,039
WITHIN FIVE BUSINESS DAYS AFTER THE HEALTH INSURING CORPORATION 2,040
DENIES COVERAGE.
(2) THE REVIEW OF THE HEALTH INSURING CORPORATION'S 2,042
DECISION SHALL BE CONDUCTED BY EXPERTS SELECTED BY AN INDEPENDENT 2,043
ENTITY THAT HAS BEEN RETAINED BY THE HEALTH INSURING CORPORATION 2,044
FOR THIS PURPOSE. THE INDEPENDENT ENTITY SHALL BE EITHER AN 2,045
46
ACADEMIC MEDICAL CENTER OR AN ENTITY THAT HAS AS ITS PRIMARY 2,046
FUNCTION, AND THAT RECEIVES A MAJORITY OF ITS REVENUE FROM, THE 2,047
PROVISION OF EXPERT REVIEWS AND RELATED SERVICES. 2,048
THE INDEPENDENT ENTITY SHALL SELECT A PANEL TO CONDUCT THE 2,051
REVIEW, WHICH PANEL SHALL BE COMPOSED OF AT LEAST THREE 2,052
PHYSICIANS OR OTHER PROVIDERS WHO ARE EXPERTS IN THE TREATMENT OF 2,053
THE ENROLLEE'S MEDICAL CONDITION AND KNOWLEDGEABLE ABOUT THE 2,054
RECOMMENDED OR REQUESTED THERAPY. IF THE INDEPENDENT ENTITY 2,055
RETAINED BY THE HEALTH INSURING CORPORATION IS AN ACADEMIC 2,057
MEDICAL CENTER, THE PANEL MAY INCLUDE EXPERTS AFFILIATED WITH OR 2,058
EMPLOYED BY THE ACADEMIC MEDICAL CENTER. 2,059
IN EITHER OF THE FOLLOWING CIRCUMSTANCES, AN EXCEPTION MAY 2,062
BE MADE TO THE REQUIREMENT THAT THE REVIEW BE CONDUCTED BY AN 2,063
EXPERT PANEL COMPOSED OF A MINIMUM OF THREE PHYSICIANS OR OTHER 2,064
PROVIDERS:
(a) A REVIEW MAY BE CONDUCTED BY AN EXPERT PANEL COMPOSED 2,067
OF ONLY TWO PHYSICIANS OR OTHER PROVIDERS IF AN ENROLLEE HAS 2,068
CONSENTED IN WRITING TO A REVIEW BY THE SMALLER PANEL; 2,069
(b) A REVIEW MAY BE CONDUCTED BY A SINGLE EXPERT PHYSICIAN 2,072
OR OTHER PROVIDER IF ONLY ONE EXPERT PHYSICIAN OR OTHER PROVIDER 2,073
IS AVAILABLE FOR THE REVIEW.
(3) NEITHER THE HEALTH INSURING CORPORATION NOR THE 2,075
ENROLLEE SHALL CHOOSE, OR CONTROL THE CHOICE OF, THE PHYSICIAN OR 2,077
OTHER PROVIDER EXPERTS.
(4) NEITHER THE EXPERTS NOR THE INDEPENDENT ENTITY 2,079
ARRANGING FOR THE EXPERTS' REVIEW SHALL HAVE ANY PROFESSIONAL, 2,080
FAMILIAL, OR FINANCIAL AFFILIATION WITH THE HEALTH INSURING 2,082
CORPORATION, EXCEPT THAT EXPERTS AFFILIATED WITH ACADEMIC MEDICAL 2,083
CENTERS WHO PROVIDE HEALTHCARE SERVICES TO ENROLLEES OF THE 2,084
HEALTH INSURING CORPORATION MAY SERVE AS EXPERTS ON THE REVIEW 2,085
PANEL. THIS NONAFFILIATION PROVISION DOES NOT PRECLUDE A HEALTH 2,087
INSURING CORPORATION FROM PAYING FOR THE EXPERTS' REVIEW, AS
SPECIFIED IN DIVISION (B)(5) OF THIS SECTION. THE EXPERTS SHALL 2,089
HAVE NO PATIENT-PHYSICIAN RELATIONSHIP OR OTHER AFFILIATION WITH 2,090
47
AN ENROLLEE WHOSE REQUEST FOR THERAPY IS UNDER REVIEW OR WITH A 2,091
PROVIDER WHOSE RECOMMENDATION FOR THERAPY IS UNDER REVIEW. 2,092
(5) ENROLLEES SHALL NOT BE REQUIRED TO PAY FOR THE 2,094
EXTERNAL, INDEPENDENT REVIEW. THE COSTS OF THE REVIEW SHALL BE 2,095
BORNE BY THE HEALTH INSURING CORPORATION. 2,096
(6) THE HEALTH INSURING CORPORATION SHALL PROVIDE TO THE 2,098
INDEPENDENT ENTITY ARRANGING FOR THE EXPERTS' REVIEW AND TO THE 2,100
ENROLLEE AND THE ENROLLEE'S PHYSICIAN A COPY OF THOSE MEDICAL 2,101
RECORDS IN THE HEALTH INSURING CORPORATION'S POSSESSION THAT ARE
RELEVANT TO THE ENROLLEE'S CONDITION FOR WHICH THERAPY HAS BEEN 2,104
RECOMMENDED OR REQUESTED. THE MEDICAL RECORDS SHALL BE DISCLOSED 2,105
SOLELY TO THE EXPERT REVIEWERS AND SHALL BE USED SOLELY FOR THE 2,106
PURPOSE OF THIS SECTION. 2,107
(7) THE OPINIONS OF THE EXPERTS ON THE PANEL SHALL BE 2,109
RENDERED WITHIN THIRTY DAYS AFTER THE ENROLLEE'S REQUEST FOR 2,111
REVIEW. IF THE ENROLLEE'S PHYSICIAN DETERMINES THAT A THERAPY 2,113
WOULD BE SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, 2,114
THE OPINIONS SHALL BE RENDERED WITHIN SEVEN DAYS AFTER THE
ENROLLEE'S REQUEST FOR REVIEW. 2,115
(8) EACH EXPERT ON THE PANEL SHALL PROVIDE THE INDEPENDENT 2,117
ENTITY WITH A PROFESSIONAL OPINION AS TO WHETHER THERE IS 2,118
SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE RECOMMENDED OR 2,119
REQUESTED THERAPY IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE 2,120
THAN STANDARD THERAPIES. 2,121
(9) EACH EXPERT'S OPINION SHALL BE PRESENTED IN WRITTEN 2,123
FORM AND SHALL INCLUDE THE FOLLOWING INFORMATION: 2,125
(a) A DESCRIPTION OF THE ENROLLEE'S CONDITION; 2,127
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO 2,129
DETERMINING WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE 2,130
THAT THE RECOMMENDED OR REQUESTED THERAPY IS MORE LIKELY THAN NOT 2,132
TO BE MORE BENEFICIAL TO THE ENROLLEE THAN STANDARD THERAPIES; 2,133
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS 2,135
PUBLISHED IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR 2,136
THE PUBLISHED OPINIONS OF MEDICAL EXPERTS OR SPECIALTY SOCIETIES; 2,137
48
(d) A DESCRIPTION OF THE ENROLLEE'S SUITABILITY TO RECEIVE 2,139
THE RECOMMENDED OR REQUESTED THERAPY ACCORDING TO A TREATMENT 2,140
PROTOCOL IN A CLINICAL TRIAL, IF APPLICABLE. 2,142
(10) THE INDEPENDENT ENTITY SHALL PROVIDE THE HEALTH 2,144
INSURING CORPORATION WITH THE OPINIONS OF THE EXPERTS. THE 2,146
HEALTH INSURING CORPORATION SHALL MAKE THE EXPERTS' OPINIONS
AVAILABLE TO THE ENROLLEE AND THE ENROLLEE'S PHYSICIAN, UPON 2,148
REQUEST.
(11) THE DECISION OF THE MAJORITY OF THE EXPERTS ON THE 2,150
PANEL, RENDERED PURSUANT TO DIVISION (B)(8) OF THIS SECTION, IS 2,151
BINDING ON THE HEALTH INSURING CORPORATION. IF THE OPINIONS OF 2,153
THE EXPERTS ON THE PANEL ARE EVENLY DIVIDED AS TO WHETHER THE 2,154
THERAPY SHOULD BE COVERED, THEN THE HEALTH INSURING CORPORATION'S
FINAL DECISION SHALL BE IN FAVOR OF COVERAGE. IF LESS THAN A 2,157
MAJORITY OF THE EXPERTS ON THE PANEL RECOMMEND COVERAGE OF THE 2,158
THERAPY, THE HEALTH INSURING CORPORATION MAY, IN ITS DISCRETION, 2,159
COVER THE THERAPY. HOWEVER, ANY COVERAGE PROVIDED PURSUANT TO 2,160
DIVISION (B)(11) OF THIS SECTION IS SUBJECT TO THE TERMS AND 2,161
CONDITIONS OF THE ENROLLEE'S CONTRACT WITH THE HEALTH INSURING 2,162
CORPORATION.
(12) THE HEALTH INSURING CORPORATION SHALL HAVE WRITTEN 2,164
POLICIES DESCRIBING THE EXTERNAL, INDEPENDENT REVIEW PROCESS. 2,166
THE HEALTH INSURING CORPORATION SHALL DISCLOSE THE AVAILABILITY 2,167
OF THE EXTERNAL, INDEPENDENT REVIEW PROCESS IN THE HEALTH 2,168
INSURING CORPORATION'S EVIDENCE OF COVERAGE AND DISCLOSURE FORMS. 2,170
(C) IF A HEALTH INSURING CORPORATION'S INITIAL DENIAL OF 2,172
COVERAGE FOR A THERAPY RECOMMENDED OR REQUESTED PURSUANT TO 2,173
DIVISION (A)(3) OF THIS SECTION IS BASED UPON AN EXTERNAL, 2,174
INDEPENDENT REVIEW OF THAT THERAPY MEETING THE REQUIREMENTS OF 2,175
DIVISION (B) OF THIS SECTION, THIS SECTION SHALL NOT BE A BASIS 2,177
FOR REQUIRING A SECOND EXTERNAL, INDEPENDENT REVIEW OF THE
RECOMMENDED OR REQUESTED THERAPY. 2,178
(D) THE HEALTH INSURING CORPORATION SHALL ANNUALLY FILE A 2,180
CERTIFICATE WITH THE SUPERINTENDENT OF INSURANCE CERTIFYING ITS 2,181
49
COMPLIANCE WITH THE REQUIREMENTS OF THIS SECTION. 2,182
Sec. 1753.28. (A) AS USED IN THIS SECTION: 2,184
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL 2,186
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF 2,187
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT 2,188
LAYPERSON WITH AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD 2,189
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO 2,190
RESULT IN ANY OF THE FOLLOWING: 2,191
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 2,194
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 2,195
IN SERIOUS JEOPARDY;
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,198
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,201
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING: 2,203
(a) A MEDICAL SCREENING EXAMINATION, AS REQUIRED BY 2,206
FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE EMERGENCY 2,207
DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY 2,208
AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN EMERGENCY 2,209
MEDICAL CONDITION;
(b) SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT THAT 2,212
ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN EMERGENCY MEDICAL 2,213
CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND 2,214
BURN CENTER OF THE HOSPITAL. 2,215
(3)(a) "STABILIZE" MEANS THE PROVISION OF SUCH MEDICAL 2,218
TREATMENT AS MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE 2,219
MEDICAL PROBABILITY, THAT NO MATERIAL DETERIORATION OF AN 2,220
INDIVIDUAL'S MEDICAL CONDITION IS LIKELY TO RESULT FROM OR OCCUR 2,221
DURING A TRANSFER, IF THE MEDICAL CONDITION COULD RESULT IN ANY 2,222
OF THE FOLLOWING:
(i) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 2,225
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 2,226
IN SERIOUS JEOPARDY;
(ii) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,229
50
(iii) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,232
(b) IN THE CASE OF A WOMAN HAVING CONTRACTIONS, 2,234
"STABILIZE" MEANS SUCH MEDICAL TREATMENT AS MAY BE NECESSARY TO 2,235
DELIVER, INCLUDING THE PLACENTA. 2,236
(4) "TRANSFER" HAS THE SAME MEANING AS IN SECTION 1867 OF 2,238
THE "SOCIAL SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 2,240
1395dd, AS AMENDED.
(B) A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 2,242
AGREEMENT PROVIDING COVERAGE OF BASIC HEALTH CARE SERVICES SHALL 2,244
COVER EMERGENCY SERVICES FOR ENROLLEES WITH EMERGENCY MEDICAL 2,245
CONDITIONS WITHOUT REGARD TO THE DAY OR TIME THE EMERGENCY 2,246
SERVICES ARE RENDERED OR TO WHETHER THE ENROLLEE, THE HOSPITAL'S 2,247
EMERGENCY DEPARTMENT WHERE THE SERVICES ARE RENDERED, OR AN 2,248
EMERGENCY PHYSICIAN TREATING THE ENROLLEE, OBTAINED PRIOR 2,249
AUTHORIZATION FOR THE EMERGENCY SERVICES.
(C) A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 2,251
AGREEMENT PROVIDING COVERAGE OF BASIC HEALTH CARE SERVICES SHALL 2,253
COVER BOTH OF THE FOLLOWING:
(1) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A 2,255
PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE 2,256
PRESENTS SELF WITH AN EMERGENCY MEDICAL CONDITION; 2,257
(2) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A 2,259
NONPARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE 2,261
PRESENTS SELF WITH AN EMERGENCY MEDICAL CONDITION AND ONE OF THE 2,262
FOLLOWING CIRCUMSTANCES APPLIES: 2,263
(a) DUE TO CIRCUMSTANCES BEYOND THE ENROLLEE'S CONTROL, 2,266
THE ENROLLEE WAS UNABLE TO UTILIZE A PARTICIPATING HOSPITAL'S
EMERGENCY DEPARTMENT WITHOUT SERIOUS THREAT TO LIFE OR HEALTH. 2,268
(b) A PRUDENT LAYPERSON WITH AN AVERAGE KNOWLEDGE OF 2,271
HEALTH AND MEDICINE WOULD HAVE REASONABLY BELIEVED THAT, UNDER 2,272
THE CIRCUMSTANCES, THE TIME REQUIRED TO TRAVEL TO A PARTICIPATING 2,273
HOSPITAL'S EMERGENCY DEPARTMENT COULD RESULT IN ONE OR MORE OF 2,274
THE ADVERSE HEALTH CONSEQUENCES DESCRIBED IN DIVISION (A)(1) OF 2,275
THIS SECTION.
51
(c) A PERSON AUTHORIZED BY THE HEALTH INSURING CORPORATION 2,277
REFERS THE ENROLLEE TO AN EMERGENCY DEPARTMENT AND DOES NOT 2,278
SPECIFY A PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT. 2,279
(d) AN AMBULANCE TAKES THE ENROLLEE TO A NONPARTICIPATING 2,281
HOSPITAL OTHER THAN AT THE DIRECTION OF THE ENROLLEE. 2,282
(e) THE ENROLLEE IS UNCONSCIOUS. 2,284
(f) A NATURAL DISASTER PRECLUDED THE USE OF A 2,286
PARTICIPATING EMERGENCY DEPARTMENT. 2,287
(g) THE STATUS OF A HOSPITAL CHANGED FROM PARTICIPATING TO 2,289
NONPARTICIPATING WITH RESPECT TO EMERGENCY SERVICES DURING A 2,290
CONTRACT YEAR AND NO GOOD FAITH EFFORT WAS MADE BY THE HEALTH 2,291
INSURING CORPORATION TO INFORM ENROLLEES OF THIS CHANGE. 2,292
(D) A HEALTH INSURING CORPORATION THAT PROVIDES COVERAGE 2,295
FOR EMERGENCY SERVICES SHALL INFORM ENROLLEES OF ALL OF THE 2,296
FOLLOWING:
(1) THE SCOPE OF COVERAGE FOR EMERGENCY SERVICES; 2,298
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES, INCLUDING 2,301
THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE ACCESS 2,302
SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY SERVICES; 2,303
(3) ANY COST SHARING PROVISIONS FOR EMERGENCY SERVICES; 2,305
(4) THE PROCEDURES FOR OBTAINING EMERGENCY SERVICES AND 2,307
OTHER MEDICAL SERVICES, SO THAT ENROLLEES ARE FAMILIAR WITH THE 2,308
LOCATION OF THE EMERGENCY DEPARTMENTS OF PARTICIPATING HOSPITALS 2,309
AND WITH THE LOCATION AND AVAILABILITY OF OTHER PARTICIPATING 2,310
FACILITIES OR SETTINGS AT WHICH THEY COULD RECEIVE MEDICAL 2,311
SERVICES.
Sec. 1753.30. NOTHING IN THIS CHAPTER SHALL PREVENT OR 2,313
OTHERWISE AFFECT THE APPLICATION TO ANY HEALTH CARE PLAN OF THOSE 2,314
PROVISIONS OF TITLE XVII OR XXXIX OF THE REVISED CODE THAT WOULD 2,316
OTHERWISE APPLY.
Sec. 3901.04. (A) As used in this section: 2,325
(1) "Laws of this state relating to insurance" include but 2,327
are not limited to Chapter 1751. notwithstanding section 1751.08, 2,329
CHAPTER 1753., Title XXXIX, sections 5725.18 to 5725.25, and 2,330
52
Chapter 5729. of the Revised Code. 2,331
(2) "Person" has the meaning defined in division (A) of 2,333
section 3901.19 of the Revised Code. 2,334
(B) Whenever it appears to the superintendent of 2,336
insurance, from the superintendent's files, upon complaint or 2,338
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 2,339
prohibited by the laws of this state relating to insurance, or 2,340
defined as unfair or deceptive by such laws, or when the 2,341
superintendent believes it to be in the best interest of the 2,342
public and necessary for the protection of the people in this 2,343
state, the superintendent or anyone designated by the 2,344
superintendent under the superintendent's official seal may do 2,345
any one or more of the following:
(1) Require any person to file with the superintendent, on 2,347
a form that is appropriate for review by the superintendent, an 2,348
original or additional statement or report in writing, under oath 2,349
or otherwise, as to any facts or circumstances concerning the 2,350
person's conduct of the business of insurance within this state 2,351
and as to any other information that the superintendent considers 2,352
to be material or relevant to such business; 2,353
(2) Administer oaths, summon and compel by order or 2,355
subpoena the attendance of witnesses to testify in relation to 2,356
any matter which, by the laws of this state relating to 2,357
insurance, is the subject of inquiry and investigation, and 2,358
require the production of any book, paper, or document pertaining 2,359
to such matter. A subpoena, notice, or order under this section 2,360
may be served by certified mail, return receipt requested. If 2,361
the subpoena, notice, or order is returned because of inability 2,362
to deliver, or if no return is received within thirty days of the 2,363
date of mailing, the subpoena, notice, or order may be served by 2,364
ordinary mail. If no return of ordinary mail is received within 2,365
thirty days after the date of mailing, service shall be deemed to 2,366
have been made. If the subpoena, notice, or order is returned 2,367
53
because of inability to deliver, the superintendent may designate 2,368
a person or persons to effect either personal or residence 2,369
service upon the witness. Service of any subpoena, notice, or 2,370
order and return may also be made in any manner authorized under 2,371
the Rules of Civil Procedure. Such service shall be made by an 2,372
employee of the department designated by the superintendent, a 2,373
sheriff, a deputy sheriff, an attorney, or any person authorized 2,374
by the Rules of Civil Procedure to serve process. 2,375
In the case of disobedience of any notice, order, or 2,377
subpoena served on a person or the refusal of a witness to 2,378
testify to a matter regarding which the person may lawfully be 2,380
interrogated, the court of common pleas of the county where venue
is appropriate, on application by the superintendent, may compel 2,381
obedience by attachment proceedings for contempt, as in the case 2,382
of disobedience of the requirements of a subpoena issued from 2,383
such court, or a refusal to testify therein. Witnesses shall 2,384
receive the fees and mileage allowed by section 2335.06 of the 2,385
Revised Code. All such fees, upon the presentation of proper 2,386
vouchers approved by the superintendent, shall be paid out of the 2,387
appropriation for the contingent fund of the department of 2,388
insurance. The fees and mileage of witnesses not summoned by the 2,389
superintendent or the superintendent's designee shall not be paid 2,391
by the state.
(3) In a case in which there is no administrative 2,393
procedure available to the superintendent to resolve a matter at 2,394
issue, request the attorney general to commence an action for a 2,395
declaratory judgment under Chapter 2721. of the Revised Code with 2,396
respect to the matter. 2,397
(4) Initiate criminal proceedings by presenting evidence 2,399
of the commission of any criminal offense established under the 2,400
laws of this state relating to insurance to the prosecuting 2,401
attorney of any county in which the offense may be prosecuted. 2,402
At the request of the prosecuting attorney, the attorney general 2,403
may assist in the prosecution of the violation with all the 2,404
54
rights, privileges, and powers conferred by law on prosecuting 2,405
attorneys including, but not limited to, the power to appear 2,406
before grand juries and to interrogate witnesses before grand 2,407
juries. 2,408
Sec. 3901.041. The superintendent of insurance shall 2,418
adopt, amend, and rescind rules and make adjudications, necessary 2,419
to discharge the superintendent's duties and exercise the 2,420
superintendent's powers, including, but not limited to, the 2,421
superintendent's duties and powers under Chapter CHAPTERS 1751. 2,423
AND 1753. and Title XXXIX of the Revised Code, subject to Chapter 2,424
119. of the Revised Code.
Sec. 3901.16. Any association, company, or corporation, 2,434
including a health insuring corporation, which violates any law 2,435
relating to the superintendent of insurance, any provision of 2,436
Chapter 1751. OR 1753. of the Revised Code, or any insurance law 2,438
of this state, for the violation of which no forfeiture or 2,439
penalty is elsewhere provided in the Revised Code, shall forfeit 2,440
and pay not less than one thousand nor more than ten thousand 2,441
dollars, to be recovered by an action in the name of the state 2,442
and on collection to be paid to the superintendent, who shall pay
such sum into the state treasury. 2,443
Sec. 3924.10. (A) The board of directors of the Ohio 2,453
health reinsurance program shall design the SEHC plan which, when 2,455
offered by a carrier, is eligible for reinsurance under the 2,456
program. The board shall establish the form and level of 2,457
coverage to be made available by carriers in their SEHC plan. In 2,458
designing the plan the board shall also establish benefit levels, 2,459
deductibles, coinsurance factors, exclusions, and limitations for 2,460
the plan. The forms and levels of coverage established by the 2,461
board shall specify which components of a health benefit plan 2,462
offered by a carrier may be reinsured. The SEHC plan is subject 2,463
to division (C) of section 3924.02 of the Revised Code and to the 2,465
provisions in Chapters 1751., 1753., 3923., and any other chapter 2,467
of the Revised Code that require coverage or the offer of 2,468
55
coverage of a health care service or benefit.
(B) The board shall adopt the SEHC plan within one hundred 2,471
eighty days after its appointment. The plan may include cost 2,472
containment features including any of the following:
(1) Utilization review of health care services, including 2,474
review of the medical necessity of hospital and physician 2,475
services; 2,476
(2) Case management benefit alternatives; 2,478
(3) Selective contracting with hospitals, physicians, and 2,480
other health care providers; 2,481
(4) Reasonable benefit differentials applicable to 2,483
participating and nonparticipating providers; 2,484
(5) Employee assistance program options that provide 2,486
preventive and early intervention mental health and substance 2,487
abuse services; 2,488
(6) Other provisions for the cost-effective management of 2,490
the plan. 2,491
(C) An SEHC plan established for use by health insuring 2,494
corporations shall be consistent with the basic method of 2,496
operation of such corporations.
(D) Each carrier shall certify to the superintendent of 2,498
insurance, in the form and manner prescribed by the 2,499
superintendent, that the SEHC plan filed by the carrier is in 2,501
substantial compliance with the provisions of the board SEHC 2,502
plan. Upon receipt by the superintendent of the certification, 2,503
the carrier may use the certified plan.
(E) Each carrier shall, on and after sixty days after the 2,505
date that the program becomes operational and as a condition of 2,506
transacting business in this state, renew coverage provided to 2,507
any individual or group under its SEHC plan. 2,508
Section 2. That existing sections 1751.02, 1751.03, 2,510
1751.04, 1751.12, 1751.13, 3901.04, 3901.041, 3901.16, and 2,512
3924.10 of the Revised Code are hereby repealed. 2,513
Section 3. Sections 1 and 2 of this act, except for 2,515
56
section 1751.12 of the Revised Code as amended by this act, shall 2,516
take effect October 1, 1998. Section 1751.12 of the Revised 2,518
Code, as amended by this act, shall take effect at the earliest
time permitted by law. 2,519