As Reported by the Senate Health, Human Services 1
and Aging Committee 2
123rd General Assembly 5
Regular Session Sub. H. B. No. 4 6
1999-2000 7
REPRESENTATIVES GARDNER-TIBERI-BUCHY-HARRIS-BRADING-CALLENDER- 9
CAREY-CATES-CORBIN-CORE-COUGHLIN-EVANS-GOODMAN-GRENDELL- 10
HAINES-HOOD-HOOPS-JACOBSON-JOLIVETTE-KILBANE-KREBS- 11
MAIER-MEAD-METZGER-MOTTLEY-MYERS-O'BRIEN-OLMAN-PADGETT- 12
ROMAN-SALERNO-SCHULER-SCHURING-TERWILLEGER-THOMAS-WILLAMOWSKI- 13
WINKLER-WOMER BENJAMIN-YOUNG-VESPER-HOUSEHOLDER-AUSTRIA- 15
SENATORS DRAKE-KEARNS-BLESSING-JOHNSON-SPADA
_________________________________________________________________ 17
A B I L L
To amend sections 1751.11, 1751.19, 1751.33, 19
1751.35, 1751.77, 1751.78, 1751.81, 1751.82, 21
1753.24, and 5747.01; to amend, for the purpose
of adopting new section numbers as indicated in 22
parentheses, sections 1751.83 (1751.821), 1751.84 23
(1751.822), 1751.85 (1751.823), and 1753.24
(1751.85); and to enact new sections 1751.83 and 24
1751.84 and sections 1751.811, 1751.831, 1751.87,
1751.88, 1751.89, 1753.13, 3901.80, 3901.81, 25
3901.82, 3901.83, 3901.84, 3923.65, 3923.66, 26
3923.67, 3923.68, 3923.681, 3923.69, 3923.70,
3923.75, 3923.76, 3923.77, 3923.78, and 3923.79 27
of the Revised Code to establish procedures for 29
enrollee appeals of health care coverage
decisions by health insuring corporations, 30
sickness and accident insurers, and state
employee benefit plans and to make other changes 31
in the laws related to health insuring 32
corporations, sickness and accident insurers, and
state employee benefit plans. 33
2
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 35
Section 1. That sections 1751.11, 1751.19, 1751.33, 37
1751.35, 1751.77, 1751.78, 1751.81, 1751.82, 1753.24, and 5747.01 39
be amended, sections 1751.83 (1751.821), 1751.84 (1751.822), 40
1751.85 (1751.823), and 1753.24 (1751.85) be amended for the 41
purpose of adopting new section numbers as indicated in
parentheses, and new sections 1751.83 and 1751.84 and sections 42
1751.811, 1751.831, 1751.87, 1751.88, 1751.89, 1753.13, 3901.80, 43
3901.81, 3901.82, 3901.83, 3901.84, 3923.65, 3923.66, 3923.67, 44
3923.68, 3923.681, 3923.69, 3923.70, 3923.75, 3923.76, 3923.77, 45
3923.78, and 3923.79 of the Revised Code be enacted to read as 47
follows:
Sec. 1751.11. (A) Every subscriber of a health insuring 57
corporation is entitled to an evidence of coverage for the health 58
care plan under which health care benefits are provided. 60
(B) Every subscriber of a health insuring corporation that 62
offers basic health care services is entitled to an 63
identification card or similar document that specifies the health 64
insuring corporation's name as stated in its articles of 65
incorporation, and any trade or fictitious names used by the 66
health insuring corporation. The identification card or document 67
shall list at least one TOLL-FREE telephone number that provides 68
the subscriber with access to health care, on a 69
twenty-four-hours-per-day, seven-days-per-week basis, AS TO HOW 70
HEALTH CARE SERVICES MAY BE OBTAINED. THE IDENTIFICATION CARD OR 71
DOCUMENT SHALL ALSO LIST AT LEAST ONE TOLL-FREE NUMBER THAT, 72
DURING NORMAL BUSINESS HOURS, PROVIDES THE SUBSCRIBER WITH ACCESS 73
TO INFORMATION ON THE COVERAGE AVAILABLE UNDER THE SUBSCRIBER'S 74
HEALTH CARE PLAN AND INFORMATION ON THE HEALTH CARE PLAN'S 75
INTERNAL AND EXTERNAL REVIEW PROCESSES.
(C) No evidence of coverage, or amendment to the evidence 77
of coverage, shall be delivered, issued for delivery, renewed, or 78
used, until the form of the evidence of coverage or amendment has 79
been filed by the health insuring corporation with the 80
3
superintendent of insurance. If the superintendent does not 81
disapprove the evidence of coverage or amendment within sixty 82
days after it is filed it shall be deemed approved, unless the 83
superintendent sooner gives approval for the evidence of coverage 84
or amendment. With respect to an amendment to an approved 85
evidence of coverage, the superintendent only may disapprove 86
provisions amended or added to the evidence of coverage. If the 87
superintendent determines within the sixty-day period that any 88
evidence of coverage or amendment fails to meet the requirements 89
of this section, the superintendent shall so notify the health 90
insuring corporation and it shall be unlawful for the health 91
insuring corporation to use such evidence of coverage or 92
amendment. At any time, the superintendent, upon at least thirty 94
days' written notice to a health insuring corporation, may 95
withdraw an approval, deemed or actual, of any evidence of
coverage or amendment on any of the grounds stated in this 96
section. Such disapproval shall be effected by a written order, 97
which shall state the grounds for disapproval and shall be issued 99
in accordance with Chapter 119. of the Revised Code. 101
(D) No evidence of coverage or amendment shall be 103
delivered, issued for delivery, renewed, or used: 104
(1) If it contains provisions or statements that are 106
inequitable, untrue, misleading, or deceptive; 107
(2) Unless it contains a clear, concise, and complete 109
statement of the following: 110
(a) The health care services and insurance or other 113
benefits, if any, to which the AN enrollee is entitled under the 115
health care plan;
(b) Any exclusions or limitations on the health care 118
services, type of health care services, benefits, or type of 119
benefits to be provided, including copayments; 120
(c) The AN enrollee's personal financial obligation for 122
noncovered services; 124
(d) Where and in what manner general information and 127
4
information as to how HEALTH CARE services may be obtained is 129
available, including the A TOLL-FREE telephone number; 131
(e) The premium rate with respect to individual and 133
conversion contracts, and relevant copayment provisions with 134
respect to all contracts. The statement of the premium rate, 135
however, may be contained in a separate insert. 136
(f) The method utilized by the health insuring corporation 139
for resolving enrollee complaints; 140
(g) THE UTILIZATION REVIEW, INTERNAL REVIEW, AND EXTERNAL 142
REVIEW PROCEDURES ESTABLISHED UNDER SECTIONS 1751.77 TO 1751.85 144
OF THE REVISED CODE. 146
(3) Unless it provides for the continuation of an 148
enrollee's coverage, in the event that the enrollee's coverage 149
under the group policy, contract, certificate, or agreement 150
terminates while the enrollee is receiving inpatient care in a 151
hospital. This continuation of coverage shall terminate at the 152
earliest occurrence of any of the following: 153
(a) The enrollee's discharge from the hospital; 155
(b) The determination by the enrollee's attending 157
physician that inpatient care is no longer medically indicated 158
for the enrollee; however, nothing in division (D)(3)(b) of this 161
section precludes a health insuring corporation from engaging in 162
utilization review as described in the evidence of coverage. 163
(c) The enrollee's reaching the limit for contractual 165
benefits; 166
(d) The effective date of any new coverage. 169
(4) Unless it contains a provision that states, in 171
substance, that the health insuring corporation is not a member 172
of any guaranty fund, and that in the event of the health 173
insuring corporation's insolvency, the AN enrollee is protected 174
only to the extent that the hold harmless provision required by 175
section 1751.13 of the Revised Code applies to the health care 177
services rendered; 178
(5) Unless it contains a provision that states, in 180
5
substance, that in the event of the insolvency of the health 181
insuring corporation, the AN enrollee may be financially 182
responsible for health care services rendered by a provider or 183
health care facility that is not under contract to the health 184
insuring corporation, whether or not the health insuring 185
corporation authorized the use of the provider or health care 186
facility. 187
(E) Notwithstanding divisions (C) and (D) of this section, 190
a health insuring corporation may use an evidence of coverage 191
that provides for the coverage of beneficiaries enrolled in Title 193
XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 194
U.S.C.A. 301, as amended, pursuant to a medicare contract, or an 196
evidence of coverage that provides for the coverage of 197
beneficiaries enrolled in the federal employees health benefits 198
program pursuant to 5 U.S.C.A. 8905, or an evidence of coverage 200
that provides for the coverage of beneficiaries enrolled in Title 202
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 203
U.S.C.A. 301, as amended, known as the medical assistance program 205
or medicaid, provided by the Ohio department of human services 206
under Chapter 5111. of the Revised Code, or an evidence of 207
coverage that provides for the coverage of beneficiaries under 208
any other federal health care program regulated by a federal 209
regulatory body, or an evidence of coverage that provides for the 210
coverage of beneficiaries under any contract covering officers or 211
employees of the state that has been entered into by the 213
department of administrative services, if both of the following 215
apply: 216
(1) The evidence of coverage has been approved by the 218
United States department of health and human services, the United 220
States office of personnel management, the Ohio department of 221
human services, or the department of administrative services. 222
(2) The evidence of coverage is filed with the 224
superintendent of insurance prior to use and is accompanied by 225
documentation of approval from the United States department of 227
6
health and human services, the United States office of personnel 228
management, the Ohio department of human services, or the 229
department of administrative services. 230
Sec. 1751.19. (A) A health insuring corporation shall 240
establish and maintain a complaint system that has been approved 241
by the superintendent of insurance to provide adequate and 242
reasonable procedures for the expeditious resolution of written 243
complaints initiated by subscribers or enrollees concerning any 244
matter relating to services provided, directly or indirectly, by 245
the health insuring corporation, including, but not limited to, 246
claims COMPLAINTS regarding the scope of coverage for health care 247
services, and denials, cancellations, or nonrenewals of coverage. 249
COMPLAINTS REGARDING A HEALTH INSURING CORPORATION'S DECISION TO 251
DENY, REDUCE, OR TERMINATE COVERAGE FOR HEALTH CARE SERVICES ARE
SUBJECT TO SECTION 1751.83 OF THE REVISED CODE. 252
(B) A health insuring corporation shall provide a timely 255
written response to each written complaint it receives. 256
Responses to written complaints relating to quality or 257
appropriateness of care shall set forth a statement informing the 258
complainant in detail of any rights the complainant may have to 259
submit such complaint to any professional peer review 260
organization or health insuring corporation peer review committee 261
that has been set up to monitor the quality or appropriateness of 262
provider services rendered. Such statement shall set forth the 263
name of the peer review organization or health insuring 264
corporation peer review committee, its address, telephone number, 265
and any other pertinent data that will enable the complainant to 266
seek further independent review of the complaint. Such appeal 267
shall not be made to the peer review corporation or health 268
insuring corporation peer review committee until the complaint 269
system of the health insuring corporation has been exhausted. 270
(C) Copies of complaints and responses, including medical 273
records related to those complaints, shall be available to the 274
superintendent and the director of health for inspection for 275
7
three years. Any document or information provided to the 276
superintendent pursuant to this division that contains a medical 277
record is confidential, and is not a public record subject to 278
section 149.43 of the Revised Code.
(D) A health insuring corporation shall establish and 281
maintain a procedure to accept complaints over the telephone or 282
in person. These complaints are not subject to the reporting 283
requirement under division (C) of section 1751.32 of the Revised 285
Code.
(E) A HEALTH INSURING CORPORATION MAY COMPLY WITH THIS 288
SECTION AND SECTION 1751.83 OF THE REVISED CODE BY ESTABLISHING 289
ONE SYSTEM FOR RECEIVING AND REVIEWING COMPLAINTS AND APPEALS 290
FROM ENROLLEES AND SUBSCRIBERS IF THE SYSTEM MEETS THE
REQUIREMENTS OF BOTH SECTIONS. 291
Sec. 1751.33. (A) Each health insuring corporation shall 300
provide to its subscribers, by mail, a description of the health 301
insuring corporation, its method of operation, its service area, 302
its most recent provider list, and its complaint procedure 303
established pursuant to section 1751.19 of the Revised Code, AND 305
A DESCRIPTION OF ITS UTILIZATION REVIEW, INTERNAL REVIEW, AND 306
EXTERNAL REVIEW PROCESSES ESTABLISHED UNDER SECTIONS 1751.77 TO 307
1751.85 OF THE REVISED CODE. AT THE REQUEST OF OR WITH THE 308
APPROVAL OF THE SUBSCRIBER, A HEALTH INSURING CORPORATION MAY 310
PROVIDE THIS INFORMATION BY ELECTRONIC MEANS RATHER THAN BY MAIL. 311
A health insuring corporation providing basic health care 313
services or supplemental health care services shall provide this 314
information annually. A health insuring corporation providing
only specialty health care services shall provide this 315
information biennially.
(B) Each health insuring corporation, upon the request of 318
a subscriber, shall make available its most recent statutory 319
financial statement.
Sec. 1751.35. (A) The superintendent of insurance may 329
suspend or revoke any certificate of authority issued to a health 330
8
insuring corporation under this chapter if the superintendent 331
finds that:
(1) The health insuring corporation is operating in 333
contravention of its articles of incorporation, its health care 334
plan or plans, or in a manner contrary to that described in and 335
reasonably inferred from any other information submitted under 336
section 1751.03 of the Revised Code, unless amendments to such 338
submissions have been filed and have taken effect in compliance 339
with this chapter. 340
(2) The health insuring corporation fails to issue 342
evidences of coverage in compliance with the requirements of 343
section 1751.11 of the Revised Code. 345
(3) The contractual periodic prepayments or premium rates 347
used do not comply with the requirements of section 1751.12 of 348
the Revised Code. 349
(4) The health insuring corporation enters into a 351
contract, agreement, or other arrangement with any health care 352
facility or provider, that does not comply with the requirements 353
of section 1751.13 of the Revised Code, or the corporation fails 355
to provide an annual certificate as required by section 1751.13 356
of the Revised Code. 358
(5) The director of health has certified, after a hearing 360
conducted in accordance with Chapter 119. of the Revised Code, 362
that the health insuring corporation no longer meets the 363
requirements of section 1751.04 of the Revised Code. 365
(6) The health insuring corporation is no longer 367
financially responsible and may reasonably be expected to be 368
unable to meet its obligations to enrollees or prospective 369
enrollees. 370
(7) The health insuring corporation has failed to 372
implement the complaint system that complies with the 373
requirements of section 1751.19 of the Revised Code. 376
(8) The health insuring corporation, or any agent or 378
representative of the corporation, has advertised, merchandised, 379
9
or solicited on its behalf in contravention of the requirements 380
of section 1751.31 of the Revised Code. 381
(9) The health insuring corporation has unlawfully 383
discriminated against any enrollee or prospective enrollee with 384
respect to enrollment, disenrollment, or price or quality of 385
health care services. 386
(10) The continued operation of the health insuring 388
corporation would be hazardous or otherwise detrimental to its 389
enrollees. 390
(11) The health insuring corporation has submitted false 392
information in any filing or submission required under this 393
chapter or any rule adopted under this chapter. 394
(12) The health insuring corporation has otherwise failed 396
to substantially comply with this chapter or any rule adopted 397
under this chapter. 398
(13) The health insuring corporation is not operating a 400
health care plan. 401
(14) THE HEALTH INSURING CORPORATION HAS FAILED TO COMPLY 403
WITH ANY OF THE REQUIREMENTS OF SECTIONS 1751.77 TO 1751.88 OF 404
THE REVISED CODE.
(B) A certificate of authority shall be suspended or 407
revoked only after compliance with the requirements of Chapter 408
119. of the Revised Code. 409
(C) When the certificate of authority of a health insuring 412
corporation is suspended, the health insuring corporation, during 413
the period of suspension, shall not enroll any additional 414
subscribers or enrollees except newborn children or other newly 415
acquired dependents of existing subscribers or enrollees, and 416
shall not engage in any advertising or solicitation whatsoever. 417
(D) When the certificate of authority of a health insuring 420
corporation is revoked, the health insuring corporation, 421
following the effective date of the order of revocation, shall 422
conduct no further business except as may be essential to the 423
orderly conclusion of the affairs of the health insuring 424
10
corporation. The health insuring corporation shall engage in no 425
further advertising or solicitation whatsoever. The 426
superintendent, by written order, may permit such further 427
operation of the health insuring corporation as the 428
superintendent may find to be in the best interest of enrollees, 429
to the end that enrollees will be afforded the greatest practical 430
opportunity to obtain continuing health care coverage. 431
Sec. 1751.77. As used in sections 1751.77 to 1751.86 440
1751.88 of the Revised Code, unless otherwise specifically 442
provided:
(A) "Adverse determination" means a determination by a 444
health insuring corporation or its designee utilization review 445
organization that an admission, availability of care, continued 447
stay, or other health care service covered under a policy, 448
contract, or agreement of the health insuring corporation has 450
been reviewed and, based upon the information provided, the 451
health care service does not meet the health insuring 453
corporation's requirements for benefit payment UNDER THE HEALTH 454
INSURING CORPORATION'S POLICY, CONTRACT, OR AGREEMENT, and
COVERAGE is therefore denied, reduced, or terminated. 456
(B) "Ambulatory review" means utilization review of health 458
care services performed or provided in an outpatient setting. 459
(C) "AUTHORIZED PERSON" MEANS A PARENT, GUARDIAN, OR OTHER 461
PERSON AUTHORIZED TO ACT ON BEHALF OF AN ENROLLEE WITH RESPECT TO 462
HEALTH CARE DECISIONS. 463
(D) "Case management" means a coordinated set of 465
activities conducted for individual patient management of 466
serious, complicated, protracted, or other specified health 467
conditions.
(D)(E) "Certification" means a determination by a health 469
insuring corporation or its designee utilization review 472
organization that an admission, availability of care, continued 473
stay, or other health care service covered under a policy, 474
contract, or agreement of the health insuring corporation has 476
11
been reviewed and, based upon the information provided, the 477
health care service satisfies the health insuring corporation's 478
requirements for benefit payment UNDER THE HEALTH INSURING 479
CORPORATION'S POLICY, CONTRACT, OR AGREEMENT. 480
(E)(F) "Clinical peer" means a physician when an 483
evaluation is to be made of the clinical appropriateness of 484
health care services provided by a physician. If an evaluation 485
is to be made of the clinical appropriateness of health care 486
services provided by a provider who is not a physician, "clinical 487
peer" means either a physician or a provider holding the same 488
license as the provider who provided the health care services. 489
(F)(G) "Clinical review criteria" means the written 491
screening procedures, decision abstracts, clinical protocols, and 492
practice guidelines used by a health insuring corporation to 493
determine the necessity and appropriateness of health care 495
services.
(G)(H) "Concurrent review" means utilization review 497
conducted during a patient's hospital stay or course of 498
treatment.
(H)(I) "Discharge planning" means the formal process for 500
determining, prior to a patient's discharge from a health care 501
facility, the coordination and management of the care that the 503
patient is to receive following discharge from a health care 504
facility.
(I)(J) "Participating provider" means a provider or health 506
care facility that, under a contract with a health insuring 508
corporation or with its contractor or subcontractor, has agreed 510
to provide health care services to enrollees with an expectation
of receiving payment, other than coinsurance, copayments, or 511
deductibles, directly or indirectly from the health insuring 512
corporation.
(J)(K) "Physician" means a provider authorized WHO HOLDS A 515
CERTIFICATE ISSUED under chapter CHAPTER 4731. of the Revised 517
Code to AUTHORIZING THE practice OF medicine and surgery or 519
12
osteopathic medicine and surgery OR A COMPARABLE LICENSE OR
CERTIFICATE FROM ANOTHER STATE. 520
(K)(L) "Prospective review" means utilization review that 522
is conducted prior to an admission or a course of treatment. 523
(L)(M) "Retrospective review" means utilization review of 525
medical necessity that is conducted after health care services 527
have been provided to a patient. "Retrospective review" does not 529
include the review of a claim that is limited to an evaluation of 530
reimbursement levels, veracity of documentation, accuracy of 531
coding, or adjudication of payment.
(M)(N) "Second opinion" means an opportunity or 533
requirement to obtain a clinical evaluation by a provider other 535
than the provider originally making a recommendation for proposed 536
health care services to assess the clinical necessity and 537
appropriateness of the proposed health care services. 538
(N)(O) "Utilization review" means a process used to 540
monitor the use of, or evaluate the clinical necessity, 542
appropriateness, efficacy, or efficiency of, health care 543
services, procedures, or settings. Areas of review may include 544
ambulatory review, prospective review, second opinion,
certification, concurrent review, case management, discharge 545
planning, or retrospective review. 546
(O)(P) "Utilization review organization" means an entity 548
that conducts utilization review, other than a health insuring 549
corporation performing a review of its own health care plans. 551
Sec. 1751.78. (A)(1) Sections 1751.77 to 1751.86 1751.88 561
of the Revised Code apply to any health insuring corporation that 563
provides or performs utilization review services in connection 564
with its policies, contracts, and agreements providing COVERING 565
basic health care services and to any designee of the health 566
insuring corporation, or to any utilization review organization 569
that performs utilization review functions on behalf of the 570
health insuring corporation in connection with policies,
contracts, or agreements of the health insuring corporation 571
13
providing COVERING basic health care services. 573
(2) Nothing in sections 1751.77 to 1751.82 or section 575
1751.85 1751.823 of the Revised Code shall be construed to 576
require a health insuring corporation to provide or perform 577
utilization review services in connection with health care 578
services provided under a policy, plan, or agreement of 579
supplemental health care services or specialty health care 580
services. 581
(B)(1) Each health insuring corporation shall be 584
responsible for monitoring all utilization review AND INTERNAL 585
REVIEW activities carried out by, or on behalf of, the health 587
insuring corporation and for ensuring that all requirements of 588
sections 1751.77 to 1751.86 1751.88 of the Revised Code, and any 589
rules adopted thereunder, are met. The health insuring 591
corporation shall also ensure that appropriate personnel have 592
operational responsibility for the conduct of the health insuring 593
corporation's utilization review program. 594
(2) If a health insuring corporation contracts to have a 596
utilization review organization or other entity perform the 597
utilization review functions required by sections 1751.77 to 598
1751.86 1751.88 of the Revised Code, and any rules adopted 600
thereunder, the superintendent of insurance shall hold the health 602
insuring corporation responsible for monitoring the activities of
the utilization review organization or other entity and for 603
ensuring that the requirements of those sections and rules are 604
met. 605
Sec. 1751.81. (A) As used in this section: 614
(1) "Enrollee" includes the representative of an enrollee. 616
(2) "Necessary, "NECESSARY information" includes the 619
results of any face-to-face clinical evaluation or second opinion 622
that may be required.
(B) A health insuring corporation shall maintain written 624
procedures for DETERMINING WHETHER A REQUESTED SERVICE IS A 625
SERVICE COVERED UNDER THE TERMS OF AN ENROLLEE'S POLICY, 626
14
CONTRACT, OR AGREEMENT, making utilization review determinations, 628
and for notifying enrollees, and participating providers, and 629
health care facilities acting on behalf of enrollees, of its 631
determinations.
(C) For initial PROSPECTIVE REVIEW determinations, a 634
health insuring corporation shall make the determination within 636
two business days after obtaining all necessary information 637
regarding a proposed admission, procedure, or health care service 638
requiring a review determination. 640
(1) In the case of a determination to certify an 642
admission, procedure, or health care service, the health insuring 643
corporation shall notify the provider or health care facility 644
rendering the health care service by telephone or facsimile 645
within three business days after making the initial 646
certification.
(2) In the case of an adverse determination, the health 648
insuring corporation shall notify the provider or health care 650
facility rendering the health care service by telephone within 651
three business days after making the adverse determination, and 652
shall provide written or electronic confirmation of the telephone 653
notification to the enrollee and the provider or health care 654
facility within one business day after making the telephone 655
notification.
(D) For concurrent review determinations, a health 657
insuring corporation shall make the determination within one 660
business day after obtaining all necessary information. 661
(1) In the case of a determination to certify an extended 663
stay or additional health care services, the health insuring 664
corporation shall notify the provider or health care facility 665
rendering the health care service by telephone or facsimile 666
within one business day after making the certification. 668
(2) In the case of an adverse determination, the health 670
insuring corporation shall notify the provider or health care 671
facility rendering the health care service by telephone within 672
15
one business day after making the adverse determination, and 673
shall provide written or electronic confirmation to the enrollee 674
and the provider or health care facility within one business day 675
after the telephone notification. The health care service to the 676
enrollee shall be continued, with standard copayments and 678
deductibles, if applicable, until the enrollee has been notified 679
of the determination. 680
(E) For retrospective review determinations, a health 682
insuring corporation shall make the determination within thirty 686
business days after receiving all necessary information. 687
(1) In the case of a certification, the health insuring 689
corporation may notify the enrollee and the provider or health 691
care facility rendering the health care service in writing. 692
(2) In the case of an adverse determination, the health 694
insuring corporation shall notify the enrollee and the provider 696
or health care facility rendering the health care service, in 697
writing, within five business days after making the adverse 698
determination.
(F)(1) The time frames set forth in divisions (C), (D), 701
and (E) of this section for determinations and notifications 703
shall prevail unless the seriousness of the medical condition of
the enrollee otherwise requires a more timely response from the 704
health insuring corporation. The health insuring corporation 705
shall maintain written procedures for making expedited 707
utilization review determinations and notifications of enrollees 708
and providers or health care facilities when warranted by the 709
medical condition of the enrollee. 710
(2) AN ENROLLEE, AN AUTHORIZED PERSON, THE ENROLLEE'S 712
PROVIDER, OR THE HEALTH CARE FACILITY RENDERING HEALTH CARE 713
SERVICE TO AN ENROLLEE MAY PROCEED WITH A REQUEST FOR AN INTERNAL 715
REVIEW PURSUANT TO SECTION 1751.83 OF THE REVISED CODE IF A 718
HEALTH INSURING CORPORATION FAILS TO MAKE A DETERMINATION AND 719
NOTIFICATION WITHIN THE TIME FRAMES SET FORTH IN DIVISION (C), 721
(D), OR (E) OF THIS SECTION. THE ENROLLEE MAY REQUEST A REVIEW 723
16
WITHOUT THE APPROVAL OF THE PROVIDER OR THE HEALTH CARE FACILITY 724
RENDERING THE HEALTH CARE SERVICE. THE PROVIDER OR HEALTH CARE 725
FACILITY MAY NOT REQUEST A REVIEW WITHOUT THE PRIOR CONSENT OF 726
THE ENROLLEE.
THE HEALTH INSURING CORPORATION'S FAILURE TO MAKE A 729
DETERMINATION AND NOTIFICATION WITHIN THE TIME FRAMES SET FORTH 730
IN DIVISION (C), (D), OR (E) OF THIS SECTION SHALL BE DEEMED TO 731
BE AN ADVERSE DETERMINATION BY THE HEALTH INSURING CORPORATION 732
FOR THE PURPOSE OF INITIATING AN INTERNAL REVIEW. 733
(G) A written notification of an adverse determination 735
shall include the principal reason or reasons for the 736
determination, instructions for initiating an appeal or A 738
reconsideration of the determination UNDER SECTION 1751.82 OF THE 739
REVISED CODE OR AN INTERNAL REVIEW UNDER SECTION 1751.83 OF THE 741
REVISED CODE, and instructions for requesting a written statement 742
of the clinical rationale used to make the determination. A 743
health insuring corporation shall provide the clinical rationale 745
for an adverse determination in writing to any party who received 746
notice of the adverse determination and who follows the 747
instructions for a request. 748
(H)(1) A health insuring corporation shall have written 750
procedures to address the failure or inability of a health care 752
facility, provider, or enrollee to provide all necessary 753
information for review.
(2) A HEALTH INSURING CORPORATION SHALL NOT USE 755
UNREASONABLE REQUESTS FOR INFORMATION TO DELAY MAKING A 756
DETERMINATION. 757
(3) If the health care facility, provider, or enrollee 760
will not release necessary information, the health insuring 761
corporation may deny certification. AN ENROLLEE NEED NOT BE 762
GRANTED AN INTERNAL REVIEW PURSUANT TO SECTION 1751.83 OF THE 763
REVISED CODE BASED ON A HEALTH INSURING CORPORATION'S FAILURE TO 765
MAKE A TIMELY DETERMINATION, IF THE HEALTH INSURING CORPORATION'S 766
DELAY IN MAKING A DETERMINATION AND NOTIFICATION IS CAUSED BY THE 767
17
FAILURE OF A HEALTH CARE FACILITY, PROVIDER, OR ENROLLEE TO 768
RELEASE ALL NECESSARY INFORMATION, IN WHICH CASE THE HEALTH 769
INSURING CORPORATION SHALL NOTIFY THE ENROLLEE IN WRITING OF THE 770
REASON FOR THE DELAY.
Sec. 1751.811. IN LIEU OF CONDUCTING A PROSPECTIVE, 772
CONCURRENT, OR RETROSPECTIVE REVIEW UNDER SECTION 1751.81 OF THE 773
REVISED CODE, PROVIDING A RECONSIDERATION UNDER SECTION 1751.82 775
OF THE REVISED CODE, OR CONDUCTING AN INTERNAL REVIEW UNDER 777
SECTION 1751.83 OF THE REVISED CODE, A HEALTH INSURING 778
CORPORATION MAY AFFORD AN ENROLLEE AN OPPORTUNITY FOR AN EXTERNAL 779
REVIEW UNDER SECTION 1751.84 OR 1751.85 OF THE REVISED CODE. IF 780
AN EXTERNAL REVIEW IS CONDUCTED PURSUANT TO THIS SECTION, THE 781
HEALTH INSURING CORPORATION IS NOT REQUIRED TO AFFORD THE 783
ENROLLEE AN OPPORTUNITY FOR ANY OF THE REVIEWS THAT WERE
DISREGARDED PURSUANT TO THIS SECTION, INCLUDING THE EXTERNAL 785
REVIEW THAT MAY HAVE RESULTED FROM A REVIEW THAT WAS DISREGARDED 786
PURSUANT TO THIS SECTION, UNLESS NEW CLINICAL INFORMATION IS 787
SUBMITTED TO THE HEALTH INSURING CORPORATION. 788
Sec. 1751.82. (A) In a case involving an initial A 798
PROSPECTIVE determination or a concurrent review determination, a 800
health insuring corporation shall give the provider or health
care facility rendering the health care service an opportunity to 802
request in writing on behalf of the enrollee a reconsideration of 803
an adverse determination by the reviewer making the adverse 804
determination. THE PROVIDER OR HEALTH CARE FACILITY MAY NOT 805
REQUEST A RECONSIDERATION WITHOUT THE PRIOR CONSENT OF THE 806
ENROLLEE. The reconsideration shall occur within three business 807
days after the health insuring corporation's receipt of the 808
written request for reconsideration, and shall be conducted 809
between the provider or health care facility rendering the health 810
care service and the reviewer who made the adverse determination. 812
If that reviewer cannot be available within three business days, 813
the reviewer may designate another reviewer.
(B) If the reconsideration process described in division 815
18
(A) of this section does not resolve the difference of opinion, 817
the adverse determination may be appealed by the enrollee, AN 818
AUTHORIZED PERSON, or the provider or health care facility ACTING 819
on behalf of the enrollee MAY REQUEST AN INTERNAL REVIEW UNDER 820
SECTION 1751.83 OF THE REVISED CODE. THE PROVIDER OR HEALTH CARE 821
FACILITY MAY NOT REQUEST AN INTERNAL REVIEW WITHOUT THE PRIOR 822
CONSENT OF THE ENROLLEE.
(C) Reconsideration is not a prerequisite to a standard AN 823
INTERNAL or expedited appeal EXTERNAL REVIEW of an adverse 825
determination.
(D) The time period allowed by division (A) of this 828
section for a reconsideration of an adverse determination shall 829
not apply if the seriousness of the medical condition of the 830
enrollee requires a more expedited reconsideration. The health 831
insuring corporation shall maintain written procedures for making 832
such an expedited reconsideration. 833
Sec. 1751.83 1751.821. A health insuring corporation may 843
present evidence of compliance with the requirements of sections 844
1751.77 to 1751.82 of the Revised Code by submitting evidence to 846
the superintendent of insurance of its accreditation by an
independent, private accrediting organization, such as the 847
national committee on quality assurance, the national quality 848
health council, the joint commission on accreditation of health 850
care organizations, or the American accreditation healthcare
commission/utilization review accreditation commission. The 852
superintendent, upon review of the organization's accreditation 853
process, may determine that such accreditation constitutes 854
compliance by the health insuring corporation with the 855
requirements of these sections.
Sec. 1751.84 1751.822. Each participating provider or 864
health care facility submitting a claim shall cooperate with the 866
utilization review program of a health insuring corporation or 867
utilization review organization and shall provide the health 868
insuring corporation or its designee access to an enrollee's 869
19
medical records during regular business hours, or copies of those 870
records at a reasonable cost. 871
Sec. 1751.85 1751.823. A health insuring corporation shall 880
annually file a certificate with the superintendent of insurance 882
certifying its compliance with sections 1751.77 to 1751.82 of the 883
Revised Code. 885
Sec. 1751.83. A HEALTH INSURING CORPORATION SHALL 887
ESTABLISH AND MAINTAIN AN INTERNAL REVIEW SYSTEM THAT HAS BEEN 888
APPROVED BY THE SUPERINTENDENT OF INSURANCE. THE SYSTEM SHALL 889
PROVIDE FOR REVIEW BY A CLINICAL PEER AND INCLUDE ADEQUATE AND 890
REASONABLE PROCEDURES FOR REVIEW AND RESOLUTION OF APPEALS FROM
ENROLLEES CONCERNING ADVERSE DETERMINATIONS MADE UNDER SECTION 893
1751.81 OF THE REVISED CODE, INCLUDING PROCEDURES FOR VERIFYING 894
AND REVIEWING APPEALS FROM ENROLLEES WHOSE MEDICAL CONDITIONS
REQUIRE EXPEDITED REVIEW. 895
A HEALTH INSURING CORPORATION SHALL CONSIDER AND PROVIDE A 897
WRITTEN RESPONSE TO EACH REQUEST FOR AN INTERNAL REVIEW NOT LATER 899
THAN SIXTY DAYS AFTER RECEIPT OF THE REQUEST, EXCEPT THAT IF THE 900
SERIOUSNESS OF THE ENROLLEE'S MEDICAL CONDITION REQUIRES AN 901
EXPEDITED REVIEW, THE HEALTH INSURING CORPORATION SHALL PROVIDE 902
THE WRITTEN RESPONSE NOT LATER THAN SEVEN DAYS AFTER RECEIPT OF 903
THE REQUEST. THE RESPONSE SHALL STATE THE REASON FOR THE HEALTH 907
INSURING CORPORATION'S DECISION, INFORM THE ENROLLEE OF THE RIGHT
TO PURSUE A FURTHER REVIEW, AND EXPLAIN THE PROCEDURES FOR 909
INITIATING THE REVIEW WITHIN WHICH THE ENROLLEE MUST REQUEST THE 910
REVIEW, AS SPECIFIED IN SECTION 1751.84 OR 1751.85 OF THE REVISED 911
CODE. FAILURE BY A HEALTH INSURING CORPORATION TO PROVIDE A 912
WRITTEN RESPONSE WITHIN THOSE TIME FRAMES SHALL BE DEEMED A 913
DENIAL BY THE HEALTH INSURING CORPORATION FOR PURPOSES OF 914
REQUESTING A REVIEW UNDER SECTION 1751.831, 1751.84, OR 1751.85 915
OF THE REVISED CODE. 916
IF THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, OR 920
TERMINATED COVERAGE FOR A HEALTH CARE SERVICE ON THE GROUNDS THAT 921
THE SERVICE IS NOT A SERVICE COVERED UNDER THE TERMS OF THE 922
20
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT, THE RESPONSE SHALL 923
INFORM THE ENROLLEE OF THE RIGHT TO REQUEST A REVIEW BY THE 924
SUPERINTENDENT OF INSURANCE UNDER SECTION 1751.831 OF THE REVISED 925
CODE. IF THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, OR 926
TERMINATED COVERAGE FOR A HEALTH CARE SERVICE ON THE GROUNDS THAT 927
THE SERVICE IS NOT MEDICALLY NECESSARY, THE RESPONSE SHALL INFORM 929
THE ENROLLEE OF THE RIGHT TO REQUEST AN EXTERNAL REVIEW UNDER 930
SECTION 1751.84 OF THE REVISED CODE, EXCEPT THAT IF THE ENROLLEE 932
MEETS THE CRITERIA SET FORTH IN DIVISION (A) OF SECTION 1751.85 933
OF THE REVISED CODE, THE RESPONSE SHALL INFORM THE ENROLLEE OF 934
THE RIGHT TO REQUEST AN EXTERNAL REVIEW UNDER SECTION 1751.85 OF 935
THE REVISED CODE.
THE HEALTH INSURING CORPORATION SHALL MAKE AVAILABLE TO THE 937
SUPERINTENDENT FOR INSPECTION COPIES OF ALL DOCUMENTS IN THE 938
HEALTH INSURING CORPORATION'S POSSESSION RELATED TO REVIEWS 939
CONDUCTED PURSUANT TO THIS SECTION, INCLUDING MEDICAL RECORDS 940
RELATED TO THOSE REVIEWS, AND OF RESPONSES, FOR THREE YEARS 941
FOLLOWING COMPLETION OF THE REVIEW. 942
Sec. 1751.831. THE SUPERINTENDENT OF INSURANCE SHALL 944
ESTABLISH AND MAINTAIN A SYSTEM FOR RECEIVING AND REVIEWING 945
REQUESTS FOR REVIEW FROM OR ON BEHALF OF ENROLLEES WHO, UNDER 946
SECTION 1751.83 OF THE REVISED CODE, HAVE BEEN DENIED COVERAGE OF 947
A HEALTH CARE SERVICE OR HAD COVERAGE REDUCED OR TERMINATED WHEN 948
THE GROUNDS FOR THE DENIAL, REDUCTION, OR TERMINATION IS THAT THE 949
SERVICE IS NOT A SERVICE COVERED UNDER THE TERMS OF THE 950
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT. 951
ON RECEIPT OF A WRITTEN REQUEST FROM AN ENROLLEE OR 953
AUTHORIZED PERSON, THE SUPERINTENDENT SHALL CONSIDER WHETHER THE 954
HEALTH CARE SERVICE IS A SERVICE COVERED UNDER THE TERMS OF THE 956
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT, EXCEPT THAT THE 957
SUPERINTENDENT SHALL NOT CONDUCT A REVIEW UNDER THIS SECTION 958
UNLESS THE ENROLLEE HAS EXHAUSTED THE HEALTH INSURING 959
CORPORATION'S INTERNAL REVIEW PROCESS ESTABLISHED PURSUANT TO
SECTION 1751.83 OF THE REVISED CODE. THE HEALTH INSURING 960
21
CORPORATION AND THE ENROLLEE OR AUTHORIZED PERSON SHALL PROVIDE 961
THE SUPERINTENDENT WITH ANY INFORMATION REQUIRED BY THE 962
SUPERINTENDENT THAT IS IN THEIR POSSESSION AND IS GERMANE TO THE 963
REVIEW.
UNLESS THE SUPERINTENDENT IS NOT ABLE TO DO SO BECAUSE 965
MAKING THE DETERMINATION REQUIRES RESOLUTION OF A MEDICAL ISSUE, 966
THE SUPERINTENDENT SHALL DETERMINE WHETHER THE HEALTH CARE 967
SERVICE AT ISSUE IS A SERVICE COVERED UNDER THE TERMS OF THE 968
ENROLLEE'S CONTRACT, POLICY, OR AGREEMENT. THE SUPERINTENDENT 969
SHALL NOTIFY THE ENROLLEE AND THE HEALTH INSURING CORPORATION OF 970
ITS DETERMINATION OR THAT IT IS NOT ABLE TO MAKE A DETERMINATION. 971
IF THE SUPERINTENDENT NOTIFIES THE HEALTH INSURING 973
CORPORATION THAT MAKING THE DETERMINATION REQUIRES THE RESOLUTION 974
OF A MEDICAL ISSUE, THE HEALTH INSURING CORPORATION SHALL AFFORD 975
THE ENROLLEE AN OPPORTUNITY FOR EXTERNAL REVIEW UNDER SECTION 976
1751.84 OR 1751.85 OF THE REVISED CODE. IF THE SUPERINTENDENT 977
NOTIFIES THE HEALTH INSURING CORPORATION THAT THE HEALTH SERVICE 978
IS A COVERED SERVICE, THE HEALTH INSURING CORPORATION SHALL 979
EITHER COVER THE SERVICE OR AFFORD THE ENROLLEE AN OPPORTUNITY
FOR AN EXTERNAL REVIEW UNDER SECTION 1751.84 OR 1751.85 OF THE 980
REVISED CODE. IF THE SUPERINTENDENT NOTIFIES THE HEALTH INSURING 981
CORPORATION THAT THE HEALTH CARE SERVICE IS NOT A COVERED 982
SERVICE, THE HEALTH INSURING CORPORATION IS NOT REQUIRED TO COVER 983
THE SERVICE OR AFFORD THE ENROLLEE AN EXTERNAL REVIEW. 984
Sec. 1751.84. (A) EXCEPT AS PROVIDED IN DIVISIONS (B) AND 987
(C) OF THIS SECTION, A HEALTH INSURING CORPORATION SHALL AFFORD 989
AN ENROLLEE AN OPPORTUNITY FOR AN EXTERNAL REVIEW IF BOTH OF THE 990
FOLLOWING ARE THE CASE:
(1) THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, 992
OR TERMINATED COVERAGE FOR WHAT WOULD BE A COVERED HEALTH CARE 995
SERVICE EXCEPT FOR THE FACT THAT THE HEALTH INSURING CORPORATION 996
HAS DETERMINED THAT THE HEALTH CARE SERVICE IS NOT MEDICALLY 997
NECESSARY;
(2) EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, THE 999
22
SERVICE, PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL 1,001
COST THE ENROLLEE MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED
SERVICE IS NOT COVERED BY THE HEALTH INSURING CORPORATION. 1,002
EXTERNAL REVIEW SHALL BE CONDUCTED IN ACCORDANCE WITH THIS 1,004
SECTION, EXCEPT THAT IF AN ENROLLEE WITH A TERMINAL CONDITION 1,005
MEETS ALL OF THE CRITERIA OF DIVISION (A) OF SECTION 1751.85 OF 1,006
THE REVISED CODE, AN EXTERNAL REVIEW SHALL BE CONDUCTED UNDER 1,008
THAT SECTION.
(B) AN ENROLLEE NEED NOT BE AFFORDED A REVIEW UNDER THIS 1,010
SECTION IN ANY OF THE FOLLOWING CIRCUMSTANCES: 1,011
(1) THE SUPERINTENDENT OF INSURANCE HAS DETERMINED UNDER 1,013
SECTION 1751.831 OF THE REVISED CODE THAT THE HEALTH CARE SERVICE 1,015
IS NOT A SERVICE COVERED UNDER THE TERMS OF THE ENROLLEE'S 1,016
POLICY, CONTRACT, OR AGREEMENT. 1,017
(2) EXCEPT AS PROVIDED IN SECTION 1751.811 OF THE REVISED 1,019
CODE, THE ENROLLEE HAS FAILED TO EXHAUST THE HEALTH INSURING 1,020
CORPORATION'S INTERNAL REVIEW PROCESS ESTABLISHED PURSUANT TO 1,021
SECTION 1751.83 OF THE REVISED CODE. 1,022
(3) THE ENROLLEE HAS PREVIOUSLY BEEN AFFORDED AN EXTERNAL 1,024
REVIEW FOR THE SAME ADVERSE DETERMINATION AND NO NEW CLINICAL 1,025
INFORMATION HAS BEEN SUBMITTED TO THE HEALTH INSURING 1,026
CORPORATION.
(C)(1) A HEALTH INSURING CORPORATION MAY DENY A REQUEST 1,028
FOR AN EXTERNAL REVIEW OF AN ADVERSE DETERMINATION IF IT IS 1,030
REQUESTED LATER THAN SIXTY DAYS AFTER THE ENROLLEE'S RECEIPT OF 1,031
NOTICE OF THE RESULT OF AN INTERNAL REVIEW BROUGHT UNDER SECTION 1,033
1751.83 OF THE REVISED CODE. AN EXTERNAL REVIEW MAY BE REQUESTED 1,035
BY THE ENROLLEE, AN AUTHORIZED PERSON, THE ENROLLEE'S PROVIDER, 1,037
OR A HEALTH CARE FACILITY RENDERING HEALTH CARE SERVICE TO THE 1,038
ENROLLEE. THE ENROLLEE MAY REQUEST A REVIEW WITHOUT THE APPROVAL 1,039
OF THE PROVIDER OR THE HEALTH CARE FACILITY RENDERING THE HEALTH 1,040
CARE SERVICE. THE PROVIDER OR HEALTH CARE FACILITY MAY NOT 1,041
REQUEST A REVIEW WITHOUT THE PRIOR CONSENT OF THE ENROLLEE. 1,042
(2) AN EXTERNAL REVIEW MUST BE REQUESTED IN WRITING, 1,044
23
EXCEPT THAT IF THE ENROLLEE HAS A CONDITION THAT REQUIRES 1,045
EXPEDITED REVIEW, THE REVIEW MAY BE REQUESTED ORALLY OR BY 1,046
ELECTRONIC MEANS. WHEN AN ORAL OR ELECTRONIC REQUEST FOR REVIEW 1,047
IS MADE, WRITTEN CONFIRMATION OF THE REQUEST SHALL BE SUBMITTED 1,049
TO THE HEALTH INSURING CORPORATION NOT LATER THAN FIVE DAYS AFTER 1,050
THE ORAL OR WRITTEN REQUEST IS SUBMITTED. 1,051
EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, A REQUEST FOR AN 1,053
EXTERNAL REVIEW MUST BE ACCOMPANIED BY WRITTEN CERTIFICATION FROM 1,055
THE ENROLLEE'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING THE 1,056
HEALTH CARE SERVICE TO THE ENROLLEE THAT THE PROPOSED SERVICE,
PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL COST THE 1,057
ENROLLEE MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED SERVICE 1,058
IS NOT COVERED BY THE HEALTH INSURING CORPORATION. 1,059
(3) FOR AN EXPEDITED REVIEW, THE ENROLLEE'S PROVIDER MUST 1,061
CERTIFY THAT THE ENROLLEE'S CONDITION COULD, IN THE ABSENCE OF 1,062
IMMEDIATE MEDICAL ATTENTION, RESULT IN ANY OF THE FOLLOWING: 1,064
(a) PLACING THE HEALTH OF THE ENROLLEE OR, WITH RESPECT TO 1,066
A PREGNANT WOMAN, THE HEALTH OF THE ENROLLEE OR THE UNBORN CHILD, 1,067
IN SERIOUS JEOPARDY; 1,068
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 1,070
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 1,072
(D) THE PROCEDURES USED IN CONDUCTING AN EXTERNAL REVIEW 1,074
OF AN ADVERSE DETERMINATION SHALL INCLUDE ALL OF THE FOLLOWING: 1,075
(1) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 1,077
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 1,078
SECTION 3901.80 OF THE REVISED CODE. 1,079
(2) EXCEPT AS PROVIDED IN DIVISION (D)(3) AND (4) OF THIS 1,081
SECTION, NEITHER THE CLINICAL PEER NOR ANY HEALTH CARE FACILITY 1,083
WITH WHICH THE CLINICAL PEER IS AFFILIATED SHALL HAVE ANY 1,085
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 1,086
FOLLOWING:
(a) THE HEALTH INSURING CORPORATION OR ANY OFFICER, 1,088
DIRECTOR, OR MANAGERIAL EMPLOYEE OF THE HEALTH INSURING 1,089
CORPORATION;
24
(b) THE ENROLLEE, THE ENROLLEE'S PROVIDER, OR THE PRACTICE 1,091
GROUP OF THE ENROLLEE'S PROVIDER; 1,092
(c) THE HEALTH CARE FACILITY AT WHICH THE HEALTH CARE 1,094
SERVICE REQUESTED BY THE ENROLLEE WOULD BE PROVIDED; 1,095
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 1,097
DEVICE, PROCEDURE, OR THERAPY PROPOSED FOR THE ENROLLEE. 1,098
(3) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT A 1,100
CLINICAL PEER FROM CONDUCTING A REVIEW UNDER ANY OF THE FOLLOWING 1,101
CIRCUMSTANCES:
(a) THE CLINICAL PEER IS AFFILIATED WITH AN ACADEMIC 1,103
MEDICAL CENTER THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF 1,104
THE HEALTH INSURING CORPORATION. 1,105
(b) THE CLINICAL PEER HAS STAFF PRIVILEGES AT A HEALTH 1,107
CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF 1,108
THE HEALTH INSURING CORPORATION. 1,109
(c) THE CLINICAL PEER IS A PARTICIPATING PROVIDER BUT WAS 1,111
NOT INVOLVED WITH THE HEALTH INSURING CORPORATION'S ADVERSE 1,112
DETERMINATION.
(4) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT THE 1,114
HEALTH INSURING CORPORATION FROM PAYING THE INDEPENDENT REVIEW 1,115
ORGANIZATION FOR THE CONDUCT OF THE REVIEW. 1,116
(5) AN ENROLLEE SHALL NOT BE REQUIRED TO PAY FOR ANY PART 1,118
OF THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE 1,119
BY THE HEALTH INSURING CORPORATION. 1,120
(6)(a) THE HEALTH INSURING CORPORATION SHALL PROVIDE TO 1,123
THE INDEPENDENT REVIEW ORGANIZATION CONDUCTING THE REVIEW A COPY 1,124
OF THOSE RECORDS IN ITS POSSESSION THAT ARE RELEVANT TO THE 1,125
ENROLLEE'S MEDICAL CONDITION AND THE REVIEW. THE RECORDS SHALL 1,126
BE USED SOLELY FOR THE PURPOSE OF THIS DIVISION. 1,127
AT THE REQUEST OF THE INDEPENDENT REVIEW ORGANIZATION, THE 1,130
HEALTH INSURING CORPORATION, ENROLLEE, OR THE PROVIDER OR HEALTH 1,131
CARE FACILITY RENDERING HEALTH CARE SERVICES TO THE ENROLLEE 1,132
SHALL PROVIDE ANY ADDITIONAL INFORMATION THE INDEPENDENT REVIEW 1,133
ORGANIZATION REQUESTS TO COMPLETE THE REVIEW. A REQUEST FOR 1,135
25
ADDITIONAL INFORMATION MAY BE MADE IN WRITING, ORALLY, OR BY
ELECTRONIC MEANS. THE INDEPENDENT REVIEW ORGANIZATION SHALL 1,137
SUBMIT THE REQUEST TO THE ENROLLEE AND HEALTH INSURING 1,138
CORPORATION. IF A REQUEST IS SUBMITTED ORALLY OR BY ELECTRONIC 1,139
MEANS TO AN ENROLLEE OR HEALTH INSURING CORPORATION, NOT LATER 1,140
THAN FIVE DAYS AFTER THE REQUEST IS SUBMITTED, THE INDEPENDENT 1,141
REVIEW ORGANIZATION SHALL PROVIDE WRITTEN CONFIRMATION OF THE 1,142
REQUEST. IF THE REVIEW WAS INITIATED BY A PROVIDER OR HEALTH 1,143
CARE FACILITY, A COPY OF THE REQUEST SHALL BE SUBMITTED TO THE 1,144
PROVIDER OR HEALTH CARE FACILITY.
(b) AN INDEPENDENT REVIEW ORGANIZATION IS NOT REQUIRED TO 1,146
MAKE A DECISION IF IT HAS NOT RECEIVED ANY REQUESTED INFORMATION 1,147
THAT IT CONSIDERS NECESSARY TO COMPLETE A REVIEW. AN INDEPENDENT 1,149
REVIEW ORGANIZATION THAT DOES NOT MAKE A DECISION FOR THIS REASON 1,150
SHALL NOTIFY THE ENROLLEE AND THE HEALTH INSURING CORPORATION 1,151
THAT A DECISION IS NOT BEING MADE. THE NOTICE MAY BE MADE IN 1,152
WRITING, ORALLY, OR BY ELECTRONIC MEANS. AN ORAL OR ELECTRONIC 1,153
NOTICE SHALL BE CONFIRMED IN WRITING NOT LATER THAN FIVE DAYS 1,154
AFTER THE ORAL OR ELECTRONIC NOTICE IS MADE. IF THE REVIEW WAS 1,155
INITIATED BY A PROVIDER OR HEALTH CARE FACILITY, A COPY OF THE 1,156
NOTICE SHALL BE SUBMITTED TO THE PROVIDER OR HEALTH CARE 1,157
FACILITY.
(7) THE HEALTH INSURING CORPORATION MAY ELECT TO COVER THE 1,160
SERVICE REQUESTED AND TERMINATE THE REVIEW. THE HEALTH INSURING 1,161
CORPORATION SHALL NOTIFY THE ENROLLEE AND ALL OTHER PARTIES 1,162
INVOLVED WITH THE DECISION BY MAIL OR, WITH THE CONSENT OR 1,163
APPROVAL OF THE ENROLLEE, BY ELECTRONIC MEANS.
(8) IN MAKING ITS DECISION, AN INDEPENDENT REVIEW 1,165
ORGANIZATION CONDUCTING THE REVIEW SHALL TAKE INTO ACCOUNT ALL OF 1,166
THE FOLLOWING:
(a) INFORMATION SUBMITTED BY THE HEALTH INSURING 1,168
CORPORATION, THE ENROLLEE, THE ENROLLEE'S PROVIDER, AND THE 1,169
HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE, INCLUDING 1,171
THE FOLLOWING:
26
(i) THE ENROLLEE'S MEDICAL RECORDS; 1,173
(ii) THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED 1,175
BY THE HEALTH INSURING CORPORATION TO MAKE ITS DECISION. 1,176
(b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 1,177
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 1,178
ORGANIZATIONS, INCLUDING THE NATIONAL INSTITUTES OF HEALTH OR ANY 1,180
BOARD RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH, THE
NATIONAL CANCER INSTITUTE, THE NATIONAL ACADEMY OF SCIENCES, THE 1,183
UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 1,184
FINANCING ADMINISTRATION OF THE UNITED STATES DEPARTMENT OF 1,185
HEALTH AND HUMAN SERVICES, AND THE AGENCY FOR HEALTH CARE POLICY 1,186
AND RESEARCH; 1,187
(c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 1,189
SCIENTIFIC LITERATURE, PUBLISHED OPINIONS OF NATIONALLY 1,190
RECOGNIZED MEDICAL EXPERTS, AND CLINICAL GUIDELINES ADOPTED BY 1,191
RELEVANT NATIONAL MEDICAL SOCIETIES. 1,192
(9)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 1,194
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 1,195
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 1,199
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 1,202
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 1,203
COPY OF ITS DECISION TO THE HEALTH INSURING CORPORATION AND THE 1,204
ENROLLEE. IF THE ENROLLEE'S PROVIDER OR THE HEALTH CARE FACILITY 1,205
RENDERING HEALTH CARE SERVICES TO THE ENROLLEE REQUESTED THE 1,206
REVIEW, THE INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A 1,207
COPY OF ITS DECISION TO THE ENROLLEE'S PROVIDER OR THE HEALTH 1,208
CARE FACILITY. 1,209
(b) THE INDEPENDENT REVIEW ORGANIZATION'S DECISION SHALL 1,211
INCLUDE A DESCRIPTION OF THE ENROLLEE'S CONDITION AND THE 1,213
PRINCIPAL REASONS FOR THE DECISION AND AN EXPLANATION OF THE 1,214
CLINICAL RATIONALE FOR THE DECISION. 1,215
(E) THE INDEPENDENT REVIEW ORGANIZATION SHALL BASE ITS 1,217
DECISION ON THE INFORMATION SUBMITTED UNDER DIVISION (D)(8) OF 1,218
27
THIS SECTION. IN MAKING ITS DECISION, THE INDEPENDENT REVIEW 1,219
ORGANIZATION SHALL CONSIDER SAFETY, EFFICACY, APPROPRIATENESS, 1,220
AND COST EFFECTIVENESS.
(F) THE HEALTH INSURING CORPORATION SHALL PROVIDE ANY 1,222
COVERAGE DETERMINED BY THE INDEPENDENT REVIEW ORGANIZATION'S 1,223
DECISION TO BE MEDICALLY NECESSARY, SUBJECT TO THE OTHER TERMS, 1,224
LIMITATIONS, AND CONDITIONS OF THE ENROLLEE'S CONTRACT. THE 1,225
DECISION SHALL APPLY ONLY TO THE INDIVIDUAL ENROLLEE'S EXTERNAL 1,226
REVIEW.
Sec. 1753.24 1751.85. (A) Each health insuring 1,235
corporation shall establish a reasonable external, independent 1,238
review process to examine the health insuring corporation's 1,239
coverage decisions for enrollees who meet all of the following 1,240
criteria:
(1) The enrollee has a terminal condition that, according 1,242
to the current diagnosis of the enrollee's physician, has a high 1,243
probability of causing death within two years. 1,244
(2) THE ENROLLEE REQUESTS A REVIEW NOT LATER THAN SIXTY 1,247
DAYS AFTER RECEIPT BY THE ENROLLEE OF NOTICE OF THE RESULT OF AN 1,248
INTERNAL REVIEW UNDER SECTION 1751.83 OF THE REVISED CODE. 1,249
(3) The enrollee's physician certifies that the enrollee 1,251
has the condition described in division (A)(1) of this section 1,253
and any of the following situations are applicable: 1,254
(a) Standard therapies have not been effective in 1,256
improving the condition of the enrollee; 1,258
(b) Standard therapies are not medically appropriate for 1,261
the enrollee;
(c) There is no standard therapy covered by the health 1,264
insuring corporation that is more beneficial than therapy 1,265
described in division (A)(3)(4) of this section. 1,266
(3)(4) The enrollee's physician has recommended a drug, 1,268
device, procedure, or other therapy that the physician certifies, 1,270
in writing, is likely to be more beneficial to the enrollee, in 1,271
the physician's opinion, than standard therapies, or, the 1,273
28
enrollee has requested a therapy that has been found in a
preponderance of peer-reviewed published studies to be associated 1,274
with effective clinical outcomes for the same condition. 1,275
(4)(5) The enrollee has been denied coverage by the health 1,277
insuring corporation for a drug, device, procedure, or other 1,281
therapy recommended or requested pursuant to division (A)(3)(4) 1,282
of this section, and has exhausted all THE HEALTH INSURING 1,283
CORPORATION'S internal appeals REVIEW PROCESS ESTABLISHED 1,284
PURSUANT TO SECTION 1751.83 OF THE REVISED CODE. 1,286
(5)(6) The drug, device, procedure, or other therapy, 1,288
recommended or requested pursuant to division (A)(3) of this 1,291
section, FOR WHICH COVERAGE HAS BEEN DENIED would be a covered 1,292
health care service except for the health insuring corporation's 1,294
determination that the drug, device, procedure, or other therapy 1,296
is experimental or investigational.
(B) A REVIEW SHALL BE REQUESTED IN WRITING, EXCEPT THAT IF 1,298
THE ENROLLEE'S PHYSICIAN DETERMINES THAT A THERAPY WOULD BE 1,299
SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, THE 1,300
REVIEW MAY BE REQUESTED ORALLY OR BY ELECTRONIC MEANS. WHEN AN 1,301
ORAL OR ELECTRONIC REQUEST FOR REVIEW IS MADE, WRITTEN 1,302
CONFIRMATION OF THE REQUEST SHALL BE SUBMITTED TO THE HEALTH
INSURING CORPORATION NOT LATER THAN FIVE DAYS AFTER THE ORAL OR 1,303
WRITTEN REQUEST IS SUBMITTED. 1,304
(C) The external, independent review process established 1,307
by a health insuring corporation shall meet all of the following 1,308
criteria:
(1) Except as provided in division (C)(E) of this section, 1,310
the process shall offer AFFORD all enrollees who meet the 1,312
criteria set forth in division (A) of this section the 1,314
opportunity to have the health insuring corporation's decision to 1,315
deny coverage of the recommended or requested therapy reviewed 1,317
under the process. Each eligible enrollee shall be notified of 1,319
that opportunity within five business days after the health 1,320
insuring corporation denies coverage.
29
(2) The review of the health insuring corporation's 1,322
decision shall be conducted by experts selected by an independent 1,323
entity that has been retained by the health insuring corporation 1,325
for this purpose. The independent entity shall be either an 1,328
academic medical center or an entity that has as its primary 1,330
function, and that receives a majority of its revenue from, the 1,331
provision of expert reviews and related services REVIEW 1,332
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 1,333
SECTION 3901.80 OF THE REVISED CODE. 1,334
The independent entity REVIEW ORGANIZATION shall select a 1,336
panel to conduct the review, which panel shall be composed of at 1,339
least three physicians or other providers who, THROUGH CLINICAL 1,340
EXPERIENCE IN THE PAST THREE YEARS, are experts in the treatment 1,341
of the enrollee's medical condition and knowledgeable about the 1,343
recommended or requested therapy. If the independent entity 1,344
retained by the health insuring corporation is an academic 1,346
medical center, the panel may include experts affiliated with or 1,347
employed by the academic medical center. 1,348
In either of the following circumstances, an exception may 1,351
be made to the requirement that the review be conducted by an 1,352
expert panel composed of a minimum of three physicians or other 1,353
providers:
(a) A review may be conducted by an expert panel composed 1,356
of only two physicians or other providers if an enrollee has 1,357
consented in writing to a review by the smaller panel; 1,358
(b) A review may be conducted by a single expert physician 1,361
or other provider if only one expert physician or other provider 1,362
is available for the review.
(3) Neither the health insuring corporation nor the 1,364
enrollee shall choose, or control the choice of, the physician or 1,366
other provider experts.
(4) Neither the THE SELECTED experts nor, ANY HEALTH CARE 1,369
FACILITY WITH WHICH AN EXPERT IS AFFILIATED, AND the independent 1,370
entity REVIEW ORGANIZATION arranging for the experts' review, 1,371
30
shall NOT have any professional, familial, or financial 1,372
affiliation with the ANY OF THE FOLLOWING:
(a) THE health insuring corporation, except that OR ANY 1,375
OFFICER, DIRECTOR, OR MANAGERIAL EMPLOYEE OF THE HEALTH INSURING
CORPORATION; 1,376
(b) THE ENROLLEE, THE ENROLLEE'S PHYSICIAN, OR THE 1,378
PRACTICE GROUP OF THE ENROLLEE'S PHYSICIAN; 1,379
(c) THE HEALTH CARE FACILITY AT WHICH THE RECOMMENDED OR 1,381
REQUESTED THERAPY WOULD BE PROVIDED; 1,382
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 1,384
DEVICE, PROCEDURE, OR THERAPY INVOLVED IN THE RECOMMENDED OR 1,385
REQUESTED THERAPY. 1,386
HOWEVER, experts affiliated with academic medical centers 1,389
who provide healthcare HEALTH CARE services to enrollees of the 1,390
health insuring corporation may serve as experts on the review 1,392
panel. This FURTHER, EXPERTS WITH STAFF PRIVILEGES AT A HEALTH 1,394
CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF 1,395
THE HEALTH INSURING CORPORATION, AS WELL AS EXPERTS WHO ARE 1,396
PARTICIPATING PROVIDERS, BUT WHO WERE NOT INVOLVED WITH THE 1,397
HEALTH INSURING CORPORATION'S DENIAL OF COVERAGE FOR THE THERAPY 1,398
UNDER REVIEW, MAY SERVE AS EXPERTS ON THE REVIEW PANEL. THESE 1,399
nonaffiliation provision does PROVISIONS DO not preclude a health 1,401
insuring corporation from paying for the experts' review, as
specified in division (B)(C)(5) of this section. The experts 1,403
shall have no patient-physician relationship or other affiliation 1,405
with an enrollee whose request for therapy is under review or 1,406
with a provider whose recommendation for therapy is under review. 1,407
(5) Enrollees shall not be required to pay for ANY PART OF 1,409
the external, independent COST OF THE review. The costs COST of 1,411
the review shall be borne by the health insuring corporation. 1,413
(6) The health insuring corporation shall provide to the 1,415
independent entity REVIEW ORGANIZATION arranging for the experts' 1,416
review and to the enrollee and the enrollee's physician a copy of 1,417
those medical records in the health insuring corporation's 1,418
31
possession that are relevant to the enrollee's MEDICAL condition 1,421
for which therapy has been recommended or requested AND THE 1,422
REVIEW. The medical records shall be disclosed solely to the 1,425
expert reviewers and shall be used solely for the purpose of this
section. AT THE REQUEST OF THE EXPERT REVIEWERS, THE HEALTH 1,427
INSURING CORPORATION OR THE PHYSICIAN RECOMMENDING THE THERAPY 1,428
SHALL PROVIDE ANY ADDITIONAL INFORMATION THAT THE EXPERT 1,429
REVIEWERS REQUEST TO COMPLETE THE REVIEW. AN EXPERT REVIEWER IS 1,430
NOT REQUIRED TO RENDER AN OPINION IF THE REVIEWER HAS NOT 1,431
RECEIVED ANY REQUESTED INFORMATION THAT THE REVIEWER CONSIDERS 1,432
NECESSARY TO COMPLETE THE REVIEW. 1,433
(7)(a) The opinions of the experts on the panel shall be 1,435
rendered within thirty days after the enrollee's request for 1,438
review. If the enrollee's physician determines that a therapy 1,440
would be significantly less effective if not promptly initiated, 1,441
the opinions shall be rendered within seven days after the
enrollee's request for review. 1,442
(b) IN CONDUCTING THE REVIEW, THE CLINICAL PEERS ON THE 1,444
PANEL SHALL TAKE INTO ACCOUNT ALL OF THE FOLLOWING: 1,446
(i) INFORMATION SUBMITTED BY THE HEALTH INSURING 1,448
CORPORATION, THE ENROLLEE, AND THE ENROLLEE'S PHYSICIAN, 1,449
INCLUDING THE ENROLLEE'S MEDICAL RECORDS AND THE STANDARDS, 1,450
CRITERIA, AND CLINICAL RATIONALE USED BY THE HEALTH INSURING 1,451
CORPORATION TO REACH ITS COVERAGE DECISION; 1,452
(ii) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 1,454
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 1,455
ORGANIZATIONS;
(iii) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 1,457
SCIENTIFIC LITERATURE AND PUBLISHED OPINIONS OF NATIONALLY 1,458
RECOGNIZED MEDICAL EXPERTS; 1,459
(iv) CLINICAL GUIDELINES ADOPTED BY RELEVANT NATIONAL 1,461
MEDICAL SOCIETIES; 1,462
(v) SAFETY, EFFICACY, APPROPRIATENESS, AND COST 1,464
EFFECTIVENESS.
32
(8) Each expert on the panel shall provide the independent 1,466
entity REVIEW ORGANIZATION with a professional opinion as to 1,468
whether there is sufficient evidence to demonstrate that the 1,469
recommended or requested therapy is likely to be more beneficial
to the enrollee than standard therapies. 1,471
(9) Each expert's opinion shall be presented in written 1,473
form and shall include the following information: 1,475
(a) A description of the enrollee's condition; 1,477
(b) A description of the indicators relevant to 1,479
determining whether there is sufficient evidence to demonstrate 1,480
that the recommended or requested therapy is more likely than not 1,482
to be more beneficial to the enrollee than standard therapies; 1,483
(c) A description and analysis of any relevant findings 1,485
published in peer-reviewed medical or scientific literature or 1,486
the published opinions of medical experts or specialty societies; 1,487
(d) A description of the enrollee's suitability to receive 1,489
the recommended or requested therapy according to a treatment 1,490
protocol in a clinical trial, if applicable. 1,492
(10) The independent entity REVIEW ORGANIZATION shall 1,494
provide the health insuring corporation with the opinions of the 1,496
experts. The health insuring corporation shall make the experts' 1,497
opinions available to the enrollee and the enrollee's physician, 1,499
upon request.
(11) The decision OPINION of the majority of the experts 1,501
on the panel, rendered pursuant to division (B)(C)(8) of this 1,503
section, is binding on the health insuring corporation with 1,505
respect to that enrollee. If the opinions of the experts on the 1,506
panel are evenly divided as to whether the therapy should be 1,507
covered, then the health insuring corporation's final decision 1,508
shall be in favor of coverage. If less than a majority of the 1,510
experts on the panel recommend coverage of the therapy, the 1,511
health insuring corporation may, in its discretion, cover the 1,512
therapy. However, any coverage provided pursuant to division 1,513
(B)(C)(11) of this section is subject to the terms, LIMITATIONS, 1,515
33
and conditions of the enrollee's contract with the health 1,517
insuring corporation.
(12) The health insuring corporation shall have written 1,519
policies describing the external, independent review process. 1,521
The health insuring corporation shall disclose the availability 1,522
of the external, independent review process in the health 1,523
insuring corporation's evidence of coverage and disclosure forms. 1,525
(C)(D) AT ANY TIME DURING THE EXTERNAL, INDEPENDENT REVIEW 1,528
PROCESS, THE HEALTH INSURING CORPORATION MAY ELECT TO COVER THE 1,529
RECOMMENDED OR REQUESTED HEALTH CARE SERVICE AND TERMINATE THE 1,530
REVIEW. THE HEALTH INSURING CORPORATION SHALL NOTIFY THE 1,531
ENROLLEE AND ALL OTHER PARTIES INVOLVED BY MAIL OR, WITH THE 1,532
CONSENT OR APPROVAL OF THE ENROLLEE, BY ELECTRONIC MEANS. 1,533
(E) If a health insuring corporation's initial denial of 1,535
coverage for a therapy recommended or requested pursuant to 1,536
division (A)(3)(4) of this section is based upon an external, 1,537
independent review of that therapy meeting the requirements of 1,538
division (B)(C) of this section, this section shall not be a 1,539
basis for requiring a second external, independent review of the 1,540
recommended or requested therapy. 1,541
(D)(F) The health insuring corporation shall annually file 1,543
a certificate with the superintendent of insurance certifying its 1,544
compliance with the requirements of this section. 1,545
Sec. 1751.87. NOTHING IN SECTIONS 1751.77 TO 1751.85 OF 1,547
THE REVISED CODE SHALL BE CONSTRUED TO CREATE A CAUSE OF ACTION 1,548
AGAINST ANY OF THE FOLLOWING:
(A) AN EMPLOYER THAT PROVIDES HEALTH CARE BENEFITS TO 1,551
EMPLOYEES THROUGH A HEALTH INSURING CORPORATION;
(B) A CLINICAL PEER OR INDEPENDENT REVIEW ORGANIZATION 1,553
THAT PARTICIPATES IN AN EXTERNAL REVIEW UNDER SECTION 1751.84 OR 1,555
1751.85 OF THE REVISED CODE;
(C) A HEALTH INSURING CORPORATION THAT PROVIDES COVERAGE 1,558
FOR BENEFITS IN ACCORDANCE WITH DIVISION (F) OF SECTION 1751.84 1,559
OR DIVISION (C)(11) OF SECTION 1751.85 OF THE REVISED CODE. 1,561
34
Sec. 1751.88. CONSISTENT WITH THE RULES OF EVIDENCE, A 1,564
WRITTEN DECISION OR OPINION PREPARED BY OR FOR AN INDEPENDENT 1,565
REVIEW ORGANIZATION UNDER SECTION 1751.84 OR 1751.85 OF THE 1,567
REVISED CODE SHALL BE ADMISSIBLE IN ANY CIVIL ACTION RELATED TO 1,568
THE COVERAGE DECISION THAT WAS THE SUBJECT OF THE DECISION OR 1,569
OPINION. THE INDEPENDENT REVIEW ORGANIZATION'S DECISION OR 1,570
OPINION SHALL BE PRESUMED TO BE A SCIENTIFICALLY VALID AND 1,573
ACCURATE DESCRIPTION OF THE STATE OF MEDICAL KNOWLEDGE AT THE
TIME IT WAS WRITTEN. 1,574
CONSISTENT WITH THE RULES OF EVIDENCE, ANY PARTY TO A CIVIL 1,576
ACTION RELATED TO A HEALTH INSURING CORPORATION'S COVERAGE 1,577
DECISION INVOLVING AN INVESTIGATIONAL OR EXPERIMENTAL DRUG, 1,579
DEVICE, OR TREATMENT MAY INTRODUCE INTO EVIDENCE ANY APPLICABLE 1,580
MEDICARE REIMBURSEMENT STANDARDS ESTABLISHED UNDER TITLE XVIII OF 1,581
THE "SOCIAL SECURITY ACT," 49 STAT. 620(1935), 42 U.S.C.A. 301, 1,583
AS AMENDED. 1,584
Sec. 1751.89. SECTIONS 1751.77 TO 1751.85 OF THE REVISED 1,587
CODE DO NOT APPLY TO EITHER OF THE FOLLOWING:
(A) COVERAGE PROVIDED TO BENEFICIARIES ENROLLED IN THE 1,589
MEDICARE+CHOICE PROGRAM OPERATED UNDER TITLE XVIII OF THE "SOCIAL 1,591
SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED; 1,592
(B) COVERAGE PROVIDED TO RECIPIENTS OF ASSISTANCE UNDER 1,594
THE MEDICAID PROGRAM OPERATED PURSUANT TO CHAPTER 5111. OF THE 1,596
REVISED CODE.
Sec. 1753.13. EVERY INDIVIDUAL OR GROUP HEALTH INSURING 1,598
CORPORATION POLICY, CONTRACT, OR AGREEMENT THAT PROVIDES BASIC 1,599
HEALTH CARE SERVICES BUT DOES NOT ALLOW DIRECT ACCESS TO 1,600
OBSTETRICIANS OR GYNECOLOGISTS SHALL PERMIT A FEMALE ENROLLEE TO 1,601
OBTAIN COVERED OBSTETRIC AND GYNECOLOGICAL SERVICES FROM A 1,602
PARTICIPATING OBSTETRICIAN OR GYNECOLOGIST WITHOUT OBTAINING A 1,604
REFERRAL FROM THE ENROLLEE'S PRIMARY CARE PROVIDER. 1,605
NO INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION POLICY, 1,607
CONTRACT, OR AGREEMENT MAY LIMIT THE NUMBER OF ALLOWABLE VISITS 1,608
TO A PARTICIPATING OBSTETRICIAN OR GYNECOLOGIST. A HEALTH 1,609
35
INSURING CORPORATION MAY REQUIRE A PARTICIPATING OBSTETRICIAN OR 1,610
GYNECOLOGIST TO COMPLY WITH THE HEALTH INSURING CORPORATION'S 1,611
COVERAGE PROTOCOLS AND PROCEDURES, INCLUDING UTILIZATION REVIEW, 1,612
FOR OBSTETRIC AND GYNECOLOGICAL SERVICES. 1,613
A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 1,615
AGREEMENT MAY NOT IMPOSE ADDITIONAL COPAYMENTS FOR DIRECTLY 1,617
ACCESSED OBSTETRIC AND GYNECOLOGICAL SERVICES, UNLESS THE POLICY, 1,618
CONTRACT, OR AGREEMENT IMPOSES ADDITIONAL COPAYMENTS FOR DIRECT
ACCESS TO ANY PARTICIPATING PROVIDER OTHER THAN A PRIMARY CARE 1,619
PROVIDER.
Sec. 3901.80. AS USED IN SECTIONS 3901.80 TO 3901.83 OF 1,621
THE REVISED CODE, "CLINICAL PEER" AND "PHYSICIAN" HAVE THE SAME 1,622
MEANINGS AS IN SECTION 1751.77 OF THE REVISED CODE.
(A) THE SUPERINTENDENT OF INSURANCE SHALL ACCREDIT 1,625
INDEPENDENT REVIEW ORGANIZATIONS FOR THE PURPOSES OF EXTERNAL
REVIEWS CONDUCTED UNDER SECTIONS 1751.84, 1751.85, 3923.67, 1,627
3923.68, 3923.76, AND 3923.77 OF THE REVISED CODE. THE
SUPERINTENDENT MAY, IN ACCORDANCE WITH CHAPTER 119. OF THE 1,628
REVISED CODE AND IN CONSULTATION WITH THE DIRECTOR OF HEALTH, 1,629
ADOPT RULES GOVERNING THE ACCREDITATION OF INDEPENDENT REVIEW 1,630
ORGANIZATIONS. IN DEVELOPING THE RULES, THE SUPERINTENDENT MAY 1,631
TAKE INTO CONSIDERATION THE STANDARDS ESTABLISHED BY NATIONAL 1,632
ORGANIZATIONS THAT ACCREDIT ORGANIZATIONS PROVIDING EXPERT 1,633
REVIEWS AND RELATED SERVICES. THE SUPERINTENDENT, AFTER 1,634
REVIEWING THE ACCREDITATION PROCESS USED BY A NATIONAL 1,635
ORGANIZATION TO ACCREDIT AN INDEPENDENT REVIEW ORGANIZATION, MAY 1,636
DETERMINE THAT ACCREDITATION BY THE NATIONAL ORGANIZATION 1,637
CONSTITUTES ACCREDITATION BY THE SUPERINTENDENT. THE 1,638
SUPERINTENDENT SHALL NOT ACCREDIT ANY INDEPENDENT REVIEW 1,639
ORGANIZATION THAT IS OPERATED BY A NATIONAL, STATE, OR LOCAL
TRADE ASSOCIATION OF HEALTH BENEFIT PLANS OR HEALTH CARE 1,640
PROVIDERS.
(B) EACH INDEPENDENT REVIEW ORGANIZATION SHALL USE THE 1,642
SERVICES OF CLINICAL PEERS OUTSIDE THE STAFF OF THE INDEPENDENT 1,643
36
REVIEW ORGANIZATION TO CONDUCT EXTERNAL REVIEWS. NONE OF THE 1,644
FOLLOWING SHALL CHOOSE, OR CONTROL THE CHOICE OF, THE CLINICAL 1,645
PEERS:
(1) A HEALTH INSURING CORPORATION; 1,647
(2) AN ENROLLEE; 1,649
(3) AN INSURER; 1,651
(4) AN INSURED; 1,653
(5) A PUBLIC EMPLOYEE BENEFIT PLAN; 1,655
(6) A PLAN MEMBER. 1,657
(C) THE SUPERINTENDENT SHALL MAINTAIN A RANDOMLY ORGANIZED 1,659
ROSTER OF INDEPENDENT REVIEW ORGANIZATIONS ACCREDITED UNDER THIS 1,660
SECTION FOR PURPOSES OF ASSIGNING INDEPENDENT REVIEW 1,661
ORGANIZATIONS TO CONDUCT EXTERNAL REVIEWS. THE SUPERINTENDENT 1,662
MAY, IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, ADOPT 1,663
RULES GOVERNING THE ASSIGNMENT OF INDEPENDENT REVIEW 1,664
ORGANIZATIONS.
ON RECEIPT OF A REQUEST BY A HEALTH INSURING CORPORATION, 1,666
INSURER, OR PUBLIC EMPLOYEE BENEFIT PLAN, THE SUPERINTENDENT 1,667
SHALL RANDOMLY ASSIGN TWO INDEPENDENT REVIEW ORGANIZATIONS THAT 1,668
ARE ACCREDITED UNDER DIVISION (A) OF THIS SECTION. AFTER RECEIPT 1,669
OF THE NAMES OF THE TWO INDEPENDENT REVIEW ORGANIZATIONS, THE 1,671
HEALTH INSURING CORPORATION, INSURER, OR PUBLIC EMPLOYEE BENEFIT 1,672
PLAN SHALL SELECT ONE OF THE ASSIGNED INDEPENDENT REVIEW
ORGANIZATIONS TO CONDUCT THE EXTERNAL REVIEW. 1,673
NO HEALTH INSURING CORPORATION, INSURER, OR PUBLIC EMPLOYEE 1,675
BENEFIT PLAN SHALL ENGAGE IN A PATTERN OF EXCLUDING A PARTICULAR 1,676
INDEPENDENT REVIEW ORGANIZATION BASED ON PREVIOUS FINDINGS ON 1,677
BEHALF OF ENROLLEES, INSUREDS, OR PLAN MEMBERS. IF THE 1,678
SUPERINTENDENT MAKES SUCH A FINDING, IT IS AN UNFAIR TRADE 1,679
PRACTICE.
Sec. 3901.81. AN INDEPENDENT REVIEW ORGANIZATION SELECTED 1,681
UNDER SECTION 3901.80 OF THE REVISED CODE TO CONDUCT AN EXTERNAL 1,682
REVIEW UNDER SECTION 1751.84, 3923.67, OR 3923.76 OF THE REVISED 1,683
CODE SHALL UTILIZE THE SERVICES OF CLINICAL PEERS WHO HAVE 1,684
37
EXPERTISE IN THE TREATMENT OF THE MEDICAL CONDITION OF THE 1,686
ENROLLEE, INSURED, OR PLAN MEMBER AND CLINICAL EXPERIENCE IN THE 1,687
PAST THREE YEARS WITH THE SERVICE REQUESTED OR RECOMMENDED BY THE 1,688
ENROLLEE, INSURED, OR PLAN MEMBER OR THE PROVIDER OF THE 1,689
ENROLLEE, INSURED, OR PLAN MEMBER. THE REVIEW SHALL BE CONDUCTED 1,690
BY A SINGLE CLINICAL PEER, UNLESS THE HEALTH INSURING 1,691
CORPORATION, INSURER, OR PUBLIC EMPLOYEE BENEFIT PLAN DETERMINES 1,693
THAT MORE THAN ONE CLINICAL PEER IS NEEDED. THE CLINICAL PEER 1,694
MUST HOLD A LICENSE THAT IS NOT RESTRICTED IN ANY MANNER BY THE 1,695
STATE IN WHICH THE CLINICAL PEER IS LICENSED. THE CLINICAL PEER 1,696
SHALL NOT HAVE BEEN DISCIPLINED OR SANCTIONED BY A HOSPITAL OR 1,698
GOVERNMENT ENTITY BASED ON THE QUALITY OF CARE PROVIDED BY THE 1,699
CLINICAL PEER. IN THE CASE OF A PHYSICIAN, THE CLINICAL PEER 1,700
MUST BE CERTIFIED BY A NATIONALLY RECOGNIZED MEDICAL SPECIALTY 1,701
BOARD IN THE AREA THAT IS THE SUBJECT OF THE REVIEW.
Sec. 3901.82. (A) EACH INDEPENDENT REVIEW ORGANIZATION 1,704
THAT CONDUCTS EXTERNAL REVIEWS UNDER SECTION 1751.84, 1751.85, 1,708
3923.67, 3923.68, 3923.76, OR 3923.77 OF THE REVISED CODE SHALL 1,709
ANNUALLY REPORT THE FOLLOWING INFORMATION TO THE SUPERINTENDENT 1,711
OF INSURANCE IN A FORMAT PRESCRIBED BY THE SUPERINTENDENT: 1,712
(1) THE NUMBER OF REVIEWS CONDUCTED; 1,714
(2) THE NUMBER OF REVIEWS DECIDED IN FAVOR OF ENROLLEES, 1,716
INSUREDS, AND PLAN MEMBERS AND THE NUMBER DECIDED IN FAVOR OF 1,718
HEALTH INSURING CORPORATIONS, INSURERS, AND PUBLIC EMPLOYEE 1,719
BENEFIT PLANS;
(3) THE AVERAGE TIME REQUIRED TO CONDUCT A REVIEW; 1,721
(4) THE NUMBER AND PERCENTAGE OF REVIEWS IN WHICH A 1,723
DECISION WAS NOT REACHED IN THE TIME REQUIRED UNDER DIVISION (D) 1,724
OF SECTION 1751.84, DIVISION (C) OF SECTION 1751.85, DIVISION (D) 1,725
OF SECTION 3923.67, DIVISION (C) OF SECTION 3923.68, DIVISION (D) 1,727
OF SECTION 3923.76, OR DIVISION (C) OF SECTION 3923.77 OF THE 1,728
REVISED CODE; 1,729
(5) A SUMMARY OF THE DIAGNOSES, DRUGS, DEVICES, SERVICES, 1,731
PROCEDURES, AND THERAPIES THAT HAVE BEEN THE SUBJECT OF EXTERNAL 1,732
38
REVIEW;
(6) THE COSTS ASSOCIATED WITH EXTERNAL REVIEWS, INCLUDING 1,734
THE RATES CHARGED BY THE INDEPENDENT REVIEW ORGANIZATION TO 1,736
CONDUCT THE REVIEWS;
(7) THE MEDICAL SPECIALTY OR TYPE OF PROVIDER USED TO 1,738
CONDUCT EACH EXTERNAL REVIEW, AS RELATED TO THE SPECIFIC MEDICAL 1,739
CONDITION OF THE ENROLLEE, INSURED, OR PLAN MEMBER; 1,740
(8) ANY ADDITIONAL INFORMATION REQUIRED BY THE 1,742
SUPERINTENDENT BY RULE ADOPTED PURSUANT TO DIVISION (C) OF THIS 1,743
SECTION.
(B) THE SUPERINTENDENT OF INSURANCE SHALL COMPLY WITH 1,745
APPLICABLE STATE AND FEDERAL LAWS RELATED TO THE CONFIDENTIALITY 1,746
OF MEDICAL RECORDS.
(C) THE SUPERINTENDENT MAY, IN ACCORDANCE WITH CHAPTER 1,748
119. OF THE REVISED CODE, ADOPT RULES REQUIRING INDEPENDENT 1,751
REVIEW ORGANIZATIONS TO PROVIDE ADDITIONAL INFORMATION ON THE 1,753
CONSIDERATION AND DISPOSITION OF EXTERNAL REVIEWS BROUGHT UNDER 1,756
SECTION 1751.84, 1751.85, 3923.67, 3923.68, 3923.76, OR 3923.77
OF THE REVISED CODE. 1,757
(D) THE SUPERINTENDENT SHALL COMPILE AND ANNUALLY PUBLISH 1,759
THE INFORMATION COLLECTED UNDER THIS SECTION AND REPORT THE 1,762
INFORMATION TO THE GOVERNOR, THE SPEAKER AND MINORITY LEADER OF 1,763
THE HOUSE OF REPRESENTATIVES, THE PRESIDENT AND MINORITY LEADER 1,765
OF THE SENATE, AND THE CHAIRS AND RANKING MINORITY MEMBERS OF THE 1,766
HOUSE AND SENATE COMMITTEES WITH JURISDICTION OVER HEALTH AND 1,768
INSURANCE ISSUES.
Sec. 3901.83. WHEN A RECORD CONTAINING INFORMATION 1,770
PERTAINING TO THE MEDICAL HISTORY, DIAGNOSIS, PROGNOSIS, OR 1,771
MEDICAL CONDITION OF AN ENROLLEE OF A HEALTH INSURING 1,772
CORPORATION, INSURED OF AN INSURER, OR PLAN MEMBER OF A PUBLIC 1,773
EMPLOYEE BENEFIT PLAN IS PROVIDED TO THE SUPERINTENDENT OF 1,774
INSURANCE FOR ANY REASON UNDER SECTIONS 1751.77 TO 1751.88, 1,775
3923.66 TO 3923.70, OR 3923.75 TO 3923.79 OF THE REVISED CODE, 1,778
REGARDLESS OF THE SOURCE, THE SUPERINTENDENT SHALL MAINTAIN THE 1,779
39
CONFIDENTIALITY OF THE RECORD. THE RECORD IN THE 1,780
SUPERINTENDENT'S POSSESSION IS NOT A PUBLIC RECORD UNDER SECTION 1,781
149.43 OF THE REVISED CODE, EXCEPT TO THE EXTENT THAT INFORMATION 1,783
FROM THE RECORD IS USED IN PREPARING REPORTS UNDER SECTION 1,784
3901.82 OF THE REVISED CODE.
Sec. 3901.84. AN INDEPENDENT REVIEW ORGANIZATION AND ANY 1,786
MEDICAL EXPERT OR CLINICAL PEER THE ORGANIZATION USES IN 1,788
CONDUCTING AN EXTERNAL REVIEW UNDER SECTION 1751.84, 1751.85, 1,789
3923.67, 3923.68, 3923.76, OR 3923.77 OF THE REVISED CODE IS NOT 1,790
LIABLE IN DAMAGES IN A CIVIL ACTION FOR INJURY, DEATH, OR LOSS TO 1,792
PERSON OR PROPERTY AND IS NOT SUBJECT TO PROFESSIONAL 1,793
DISCIPLINARY ACTION FOR MAKING, IN GOOD FAITH, ANY FINDING,
CONCLUSION, OR DETERMINATION REQUIRED TO COMPLETE THE EXTERNAL 1,795
REVIEW.
THIS SECTION DOES NOT GRANT IMMUNITY FROM CIVIL LIABILITY 1,799
OR PROFESSIONAL DISCIPLINARY ACTION TO AN INDEPENDENT REVIEW
ORGANIZATION, MEDICAL EXPERT, OR CLINICAL PEER FOR AN ACTION THAT 1,800
IS OUTSIDE THE SCOPE OF AUTHORITY GRANTED UNDER SECTION 1751.84, 1,802
1751.85, 3923.67, 3923.68, 3923.76, OR 3923.77 OF THE REVISED 1,804
CODE.
Sec. 3923.65. (A) AS USED IN THIS SECTION: 1,806
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL 1,808
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF 1,809
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT 1,810
LAYPERSON WITH AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD 1,811
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO 1,812
RESULT IN ANY OF THE FOLLOWING: 1,813
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 1,815
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 1,816
IN SERIOUS JEOPARDY; 1,817
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 1,819
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 1,821
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING: 1,823
(a) A MEDICAL SCREENING EXAMINATION, AS REQUIRED BY 1,825
40
FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE EMERGENCY 1,826
DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY 1,828
AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN EMERGENCY 1,829
MEDICAL CONDITION; 1,830
(b) SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT THAT 1,832
ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN EMERGENCY MEDICAL 1,833
CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND 1,835
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND 1,836
BURN CENTER OF THE HOSPITAL.
(B) EVERY INDIVIDUAL OR GROUP POLICY OF SICKNESS AND 1,838
ACCIDENT INSURANCE THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL 1,839
EXPENSE COVERAGE SHALL COVER EMERGENCY SERVICES WITHOUT REGARD TO 1,840
THE DAY OR TIME THE EMERGENCY SERVICES ARE RENDERED OR TO WHETHER 1,841
THE POLICYHOLDER, THE HOSPITAL'S EMERGENCY DEPARTMENT WHERE THE 1,842
SERVICES ARE RENDERED, OR AN EMERGENCY PHYSICIAN TREATING THE 1,843
POLICYHOLDER, OBTAINED PRIOR AUTHORIZATION FOR THE EMERGENCY 1,844
SERVICES.
(C) EVERY INDIVIDUAL POLICY OR CERTIFICATE FURNISHED BY AN 1,846
INSURER IN CONNECTION WITH ANY SICKNESS AND ACCIDENT INSURANCE 1,848
POLICY SHALL PROVIDE INFORMATION REGARDING THE FOLLOWING: 1,849
(1) THE SCOPE OF COVERAGE FOR EMERGENCY SERVICES; 1,851
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES, INCLUDING 1,853
THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE ACCESS 1,854
SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY SERVICES; 1,855
(3) ANY COPAYMENTS FOR EMERGENCY SERVICES. 1,857
(D) THIS SECTION DOES NOT APPLY TO ANY INDIVIDUAL OR GROUP 1,859
POLICY OF SICKNESS AND ACCIDENT INSURANCE COVERING ONLY ACCIDENT, 1,860
CREDIT, DENTAL, DISABILITY INCOME, LONG-TERM CARE, HOSPITAL 1,861
INDEMNITY, MEDICARE SUPPLEMENT, MEDICARE, TRICARE, SPECIFIED 1,862
DISEASE, OR VISION CARE; COVERAGE UNDER A ONE-TIME LIMITED 1,863
DURATION POLICY OF NO LONGER THAN SIX MONTHS; COVERAGE ISSUED AS 1,864
A SUPPLEMENT TO LIABILITY INSURANCE; INSURANCE ARISING OUT OF 1,865
WORKERS' COMPENSATION OR SIMILAR LAW; AUTOMOBILE MEDICAL PAYMENT 1,866
INSURANCE; OR INSURANCE UNDER WHICH BENEFITS ARE PAYABLE WITH OR 1,867
41
WITHOUT REGARD TO FAULT AND WHICH IS STATUTORILY REQUIRED TO BE 1,868
CONTAINED IN ANY LIABILITY INSURANCE POLICY OR EQUIVALENT 1,869
SELF-INSURANCE.
Sec. 3923.66. (A) AS USED IN SECTIONS 3923.66 TO 3923.70 1,871
OF THE REVISED CODE: 1,872
(1) "CLINICAL PEER" AND "PHYSICIAN" HAVE THE SAME MEANINGS 1,874
AS IN SECTION 1751.77 OF THE REVISED CODE. 1,875
(2) "AUTHORIZED PERSON" MEANS A PARENT, GUARDIAN, OR OTHER 1,877
PERSON AUTHORIZED TO ACT ON BEHALF OF AN INSURED WITH RESPECT TO 1,878
HEALTH CARE DECISIONS. 1,879
(B) SECTIONS 3923.66 TO 3923.70 OF THE REVISED CODE DO NOT 1,882
APPLY TO ANY INDIVIDUAL OR GROUP POLICY OF SICKNESS AND ACCIDENT 1,884
INSURANCE COVERING ONLY ACCIDENT, CREDIT, DENTAL, DISABILITY 1,885
INCOME, LONG-TERM CARE, HOSPITAL INDEMNITY, MEDICARE SUPPLEMENT, 1,887
MEDICARE, TRICARE, SPECIFIED DISEASE, OR VISION CARE; COVERAGE 1,888
ISSUED AS A SUPPLEMENT TO LIABILITY INSURANCE; INSURANCE ARISING 1,889
OUT OF WORKERS' COMPENSATION OR SIMILAR LAW; AUTOMOBILE MEDICAL 1,890
PAYMENT INSURANCE; OR INSURANCE UNDER WHICH BENEFITS ARE PAYABLE 1,891
WITH OR WITHOUT REGARD TO FAULT AND WHICH IS STATUTORILY REQUIRED 1,892
TO BE CONTAINED IN ANY LIABILITY INSURANCE POLICY OR EQUIVALENT 1,893
SELF-INSURANCE.
(C) THE SUPERINTENDENT OF INSURANCE SHALL ESTABLISH AND 1,895
MAINTAIN A SYSTEM FOR RECEIVING AND REVIEWING REQUESTS FOR REVIEW 1,897
FROM INSUREDS WHO HAVE BEEN DENIED COVERAGE OF A HEALTH CARE 1,898
SERVICE ON THE GROUNDS THAT THE SERVICE IS NOT A SERVICE COVERED 1,899
UNDER THE TERMS OF THE INSURED'S POLICY OR CERTIFICATE. 1,900
ON RECEIPT OF A WRITTEN REQUEST FROM AN INSURED OR 1,902
AUTHORIZED PERSON, THE SUPERINTENDENT SHALL CONSIDER WHETHER THE 1,903
HEALTH CARE SERVICE IS A SERVICE COVERED UNDER THE TERMS OF THE 1,904
INSURED'S POLICY OR CERTIFICATE, EXCEPT THAT THE SUPERINTENDENT 1,905
SHALL NOT CONDUCT A REVIEW UNDER THIS SECTION UNLESS THE INSURED 1,906
HAS EXHAUSTED THE INSURER'S INTERNAL REVIEW PROCESS. THE INSURER 1,907
AND THE INSURED OR AUTHORIZED PERSON SHALL PROVIDE THE 1,908
SUPERINTENDENT WITH ANY INFORMATION REQUIRED BY THE 1,909
42
SUPERINTENDENT THAT IS IN THEIR POSSESSION AND IS GERMANE TO THE 1,910
REVIEW.
UNLESS THE SUPERINTENDENT IS NOT ABLE TO DO SO BECAUSE 1,912
MAKING THE DETERMINATION REQUIRES RESOLUTION OF A MEDICAL ISSUE, 1,913
THE SUPERINTENDENT SHALL DETERMINE WHETHER THE HEALTH CARE 1,914
SERVICE AT ISSUE IS A SERVICE COVERED UNDER THE TERMS OF THE 1,915
INSURED'S POLICY OR CERTIFICATE. THE SUPERINTENDENT SHALL NOTIFY 1,916
THE INSURED AND THE INSURER OF ITS DETERMINATION OR THAT IT IS 1,917
NOT ABLE TO MAKE A DETERMINATION BECAUSE THE DETERMINATION 1,918
REQUIRES THE RESOLUTION OF A MEDICAL ISSUE.
IF THE SUPERINTENDENT NOTIFIES THE INSURER THAT MAKING THE 1,920
DETERMINATION REQUIRES THE RESOLUTION OF A MEDICAL ISSUE, THE 1,921
INSURER SHALL AFFORD THE INSURED AN OPPORTUNITY FOR EXTERNAL 1,922
REVIEW UNDER SECTION 3923.67 OR 3923.68 OF THE REVISED CODE. IF 1,923
THE SUPERINTENDENT NOTIFIES THE INSURER THAT THE HEALTH CARE 1,924
SERVICE IS NOT A COVERED SERVICE, THE INSURER IS NOT REQUIRED TO 1,925
COVER THE SERVICE OR AFFORD THE INSURED AN EXTERNAL REVIEW. 1,927
Sec. 3923.67. (A) EXCEPT AS PROVIDED IN DIVISIONS (B) AND 1,930
(C) OF THIS SECTION, AN INSURER SHALL AFFORD AN INSURED AN 1,931
OPPORTUNITY FOR AN EXTERNAL REVIEW OF A COVERAGE DENIAL WHEN 1,932
REQUESTED BY THE INSURED OR AUTHORIZED PERSON, IF BOTH OF THE 1,933
FOLLOWING ARE THE CASE:
(1) THE INSURER HAS DENIED, REDUCED, OR TERMINATED 1,935
COVERAGE FOR WHAT WOULD BE A COVERED HEALTH CARE SERVICE EXCEPT 1,936
THAT THE INSURER HAS DETERMINED THAT THE HEALTH CARE SERVICE IS 1,937
NOT MEDICALLY NECESSARY.
(2) EXCEPT IN THE CASE OF EXPEDITED REVIEW, THE PROPOSED 1,940
SERVICE, PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL 1,941
COST THE INSURED MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED 1,942
SERVICE IS NOT COVERED BY THE INSURER. 1,943
EXTERNAL REVIEW SHALL BE CONDUCTED IN ACCORDANCE WITH THIS 1,945
SECTION, EXCEPT THAT IF AN INSURED WITH A TERMINAL CONDITION 1,946
MEETS ALL OF THE CRITERIA OF DIVISION (A) OF SECTION 3923.68 OF 1,947
THE REVISED CODE, AN EXTERNAL REVIEW SHALL BE CONDUCTED UNDER 1,949
43
THAT SECTION. 1,950
(B) AN INSURED NEED NOT BE AFFORDED A REVIEW UNDER THIS 1,952
SECTION IN ANY OF THE FOLLOWING CIRCUMSTANCES: 1,953
(1) THE SUPERINTENDENT OF INSURANCE HAS DETERMINED UNDER 1,955
SECTION 3923.66 OF THE REVISED CODE THAT THE HEALTH CARE SERVICE 1,956
IS NOT A SERVICE COVERED UNDER THE TERMS OF THE INSURED'S POLICY 1,957
OR CERTIFICATE. 1,958
(2) THE INSURED HAS FAILED TO EXHAUST THE INSURER'S 1,960
INTERNAL REVIEW PROCESS. 1,961
(3) THE INSURED HAS PREVIOUSLY AFFORDED AN EXTERNAL REVIEW 1,963
FOR THE SAME DENIAL OF COVERAGE, AND NO NEW CLINICAL INFORMATION 1,964
HAS BEEN SUBMITTED TO THE INSURER. 1,965
(C)(1) AN INSURER MAY DENY A REQUEST FOR AN EXTERNAL 1,967
REVIEW IF IT IS REQUESTED LATER THAN SIXTY DAYS AFTER RECEIPT BY 1,968
THE INSURED OF NOTICE FROM THE SUPERINTENDENT OF INSURANCE UNDER 1,969
SECTION 3923.66 OF THE REVISED CODE THAT MAKING A DETERMINATION 1,970
REQUIRES THE RESOLUTION OF A MEDICAL ISSUE. AN EXTERNAL REVIEW 1,971
MAY BE REQUESTED BY THE INSURED, AN AUTHORIZED PERSON, THE 1,972
INSURED'S PROVIDER, OR A HEALTH CARE FACILITY RENDERING HEALTH 1,973
CARE SERVICE TO THE INSURED. THE INSURED MAY REQUEST A REVIEW 1,974
WITHOUT THE APPROVAL OF THE PROVIDER OR THE HEALTH CARE FACILITY 1,975
RENDERING THE HEALTH CARE SERVICE. THE PROVIDER OR HEALTH CARE 1,976
FACILITY MAY NOT REQUEST A REVIEW WITHOUT THE PRIOR CONSENT OF 1,977
THE INSURED.
(2) AN EXTERNAL REVIEW MUST BE REQUESTED IN WRITING, 1,979
EXCEPT THAT IF THE INSURED HAS A CONDITION THAT REQUIRES 1,980
EXPEDITED REVIEW, THE REVIEW MAY BE REQUESTED ORALLY OR BY 1,981
ELECTRONIC MEANS. WHEN AN ORAL OR ELECTRONIC REQUEST FOR REVIEW 1,982
IS MADE, WRITTEN CONFIRMATION OF THE REQUEST MUST BE SUBMITTED TO 1,983
THE INSURER NOT LATER THAN FIVE DAYS AFTER THE REQUEST IS MADE. 1,984
EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, A REQUEST FOR AN 1,986
EXTERNAL REVIEW MUST BE ACCOMPANIED BY WRITTEN CERTIFICATION FROM 1,987
THE INSURED'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING THE 1,988
HEALTH CARE SERVICE TO THE INSURED THAT THE PROPOSED SERVICE, 1,989
44
PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL COST THE 1,990
INSURED MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED SERVICE IS 1,991
NOT COVERED BY THE INSURER. 1,992
(3) FOR AN EXPEDITED REVIEW, THE INSURED'S PROVIDER MUST 1,994
CERTIFY THAT THE INSURED'S CONDITION COULD, IN THE ABSENCE OF 1,995
IMMEDIATE MEDICAL ATTENTION, RESULT IN ANY OF THE FOLLOWING: 1,996
(a) PLACING THE HEALTH OF THE INSURED OR, WITH RESPECT TO 1,998
A PREGNANT WOMAN, THE HEALTH OF THE INSURED OR THE UNBORN CHILD, 1,999
IN SERIOUS JEOPARDY; 2,000
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,002
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,004
(D) THE PROCEDURES USED IN CONDUCTING AN EXTERNAL REVIEW 2,006
SHALL INCLUDE ALL OF THE FOLLOWING: 2,007
(1) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 2,009
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 2,010
SECTION 3901.80 OF THE REVISED CODE. 2,011
(2) EXCEPT AS PROVIDED IN DIVISIONS (D)(3) AND (4) OF THIS 2,013
SECTION, NEITHER THE CLINICAL PEER NOR ANY HEALTH CARE FACILITY 2,014
WITH WHICH THE CLINICAL PEER IS AFFILIATED SHALL HAVE ANY 2,015
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 2,016
FOLLOWING: 2,017
(a) THE INSURER OR ANY OFFICER, DIRECTOR, OR MANAGERIAL 2,019
EMPLOYEE OF THE INSURER; 2,021
(b) THE INSURED, THE INSURED'S PROVIDER, OR THE PRACTICE 2,023
GROUP OF THE INSURED'S PROVIDER; 2,025
(c) THE HEALTH CARE FACILITY AT WHICH THE HEALTH CARE 2,027
SERVICE REQUESTED BY THE INSURED WOULD BE PROVIDED; 2,028
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 2,030
DEVICE, PROCEDURE, OR THERAPY PROPOSED FOR THE INSURED. 2,031
(3) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT A 2,033
CLINICAL PEER FROM CONDUCTING A REVIEW UNDER ANY OF THE FOLLOWING 2,034
CIRCUMSTANCES: 2,035
(a) THE CLINICAL PEER IS AFFILIATED WITH AN ACADEMIC 2,037
MEDICAL CENTER THAT PROVIDES HEALTH CARE SERVICES TO INSUREDS OF 2,038
45
THE INSURER. 2,039
(b) THE CLINICAL PEER HAS STAFF PRIVILEGES AT A HEALTH 2,041
CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO INSUREDS OF 2,042
THE INSURER. 2,043
(c) THE CLINICAL PEER HAS A CONTRACTUAL RELATIONSHIP WITH 2,045
THE INSURER BUT WAS NOT INVOLVED WITH THE INSURER'S COVERAGE 2,046
DECISION.
(4) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT THE 2,048
INSURER FROM PAYING THE INDEPENDENT REVIEW ORGANIZATION FOR THE 2,049
CONDUCT OF THE REVIEW. 2,050
(5) AN INSURED SHALL NOT BE REQUIRED TO PAY FOR ANY PART 2,052
OF THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE 2,053
BY THE INSURER. 2,054
(6)(a) THE INSURER SHALL PROVIDE TO THE INDEPENDENT REVIEW 2,057
ORGANIZATION CONDUCTING THE REVIEW A COPY OF THOSE RECORDS IN ITS
POSSESSION THAT ARE RELEVANT TO THE INSURED'S MEDICAL CONDITION 2,060
AND THE REVIEW.
RECORDS SHALL BE USED SOLELY FOR THE PURPOSE OF THIS 2,063
DIVISION. AT THE REQUEST OF THE INDEPENDENT REVIEW ORGANIZATION, 2,064
THE INSURER, INSURED, PROVIDER, OR HEALTH CARE FACILITY RENDERING 2,065
HEALTH CARE SERVICES TO THE INSURED SHALL PROVIDE ANY ADDITIONAL 2,066
INFORMATION THE INDEPENDENT REVIEW ORGANIZATION REQUESTS TO 2,067
COMPLETE THE REVIEW. A REQUEST FOR ADDITIONAL INFORMATION MAY BE 2,068
MADE IN WRITING, ORALLY, OR BY ELECTRONIC MEANS. THE INDEPENDENT 2,069
REVIEW ORGANIZATION SHALL SUBMIT THE REQUEST TO THE INSURED AND 2,070
INSURER. IF A REQUEST IS SUBMITTED ORALLY OR BY ELECTRONIC MEANS 2,071
TO AN INSURED OR INSURER, NOT LATER THAN FIVE DAYS AFTER THE 2,072
REQUEST IS SUBMITTED, THE INDEPENDENT REVIEW ORGANIZATION SHALL 2,073
PROVIDE WRITTEN CONFIRMATION OF THE REQUEST. IF THE REVIEW WAS 2,074
INITIATED BY A PROVIDER OR HEALTH CARE FACILITY, A COPY OF THE 2,075
REQUEST SHALL BE SUBMITTED TO THE PROVIDER OR HEALTH CARE 2,076
FACILITY.
(b) AN INDEPENDENT REVIEW ORGANIZATION IS NOT REQUIRED TO 2,078
MAKE A DECISION IF IT HAS NOT RECEIVED ANY REQUESTED INFORMATION 2,080
46
THAT IT CONSIDERS NECESSARY TO COMPLETE A REVIEW. AN INDEPENDENT 2,081
REVIEW ORGANIZATION THAT DOES NOT MAKE A DECISION FOR THIS REASON 2,082
SHALL NOTIFY THE INSURED AND THE INSURER THAT A DECISION IS NOT 2,084
BEING MADE. THE NOTICE MAY BE MADE IN WRITING, ORALLY, OR BY 2,085
ELECTRONIC MEANS. AN ORAL OR ELECTRONIC NOTICE SHALL BE
CONFIRMED IN WRITING NOT LATER THAN FIVE DAYS AFTER THE ORAL OR 2,086
ELECTRONIC NOTICE IS MADE. IF THE REVIEW WAS INITIATED BY A 2,087
PROVIDER OR HEALTH CARE FACILITY, A COPY OF THE NOTICE SHALL BE 2,088
SUBMITTED TO THE PROVIDER OR HEALTH CARE FACILITY. 2,089
(7) THE INSURER MAY ELECT TO COVER THE SERVICE REQUESTED 2,092
AND TERMINATE THE REVIEW. THE INSURER SHALL NOTIFY THE INSURED 2,093
AND ALL OTHER PARTIES INVOLVED WITH THE DECISION BY MAIL, OR WITH 2,094
THE CONSENT OR APPROVAL OF THE INSURED, BY ELECTRONIC MEANS. 2,095
(8) IN MAKING ITS DECISION, AN INDEPENDENT REVIEW 2,097
ORGANIZATION CONDUCTING THE REVIEW SHALL TAKE INTO ACCOUNT ALL OF 2,098
THE FOLLOWING: 2,099
(a) INFORMATION SUBMITTED BY THE INSURER, THE INSURED, THE 2,101
INSURED'S PROVIDER, AND THE HEALTH CARE FACILITY RENDERING THE 2,102
HEALTH CARE SERVICE, INCLUDING THE FOLLOWING: 2,103
(i) THE INSURED'S MEDICAL RECORDS; 2,105
(ii) THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED 2,107
BY THE INSURER TO MAKE ITS DECISION. 2,108
(b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 2,110
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 2,111
ORGANIZATIONS, INCLUDING THE NATIONAL INSTITUTES OF HEALTH OR ANY
BOARD RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH, THE 2,112
NATIONAL CANCER INSTITUTE, THE NATIONAL ACADEMY OF SCIENCES, THE 2,113
UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 2,115
FINANCING ADMINISTRATION OF THE UNITED STATES DEPARTMENT OF 2,116
HEALTH AND HUMAN SERVICES, AND THE AGENCY FOR HEALTH CARE POLICY 2,117
AND RESEARCH; 2,118
(c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 2,120
SCIENTIFIC LITERATURE, PUBLISHED OPINIONS OF NATIONALLY 2,121
RECOGNIZED MEDICAL EXPERTS, AND CLINICAL GUIDELINES ADOPTED BY
47
RELEVANT NATIONAL MEDICAL SOCIETIES. 2,122
(9)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 2,124
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 2,125
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 2,126
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A 2,127
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 2,128
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 2,129
COPY OF ITS DECISION TO THE INSURER AND THE INSURED. IF THE 2,130
INSURED'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING HEALTH 2,131
CARE SERVICES TO THE INSURED REQUESTED THE REVIEW, THE 2,132
INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A COPY OF ITS 2,133
DECISION TO THE INSURED'S PROVIDER OR THE HEALTH CARE FACILITY. 2,134
(b) THE INDEPENDENT REVIEW ORGANIZATION'S DECISION SHALL 2,136
INCLUDE A DESCRIPTION OF THE INSURED'S CONDITION AND THE 2,137
PRINCIPAL REASONS FOR THE DECISION AND AN EXPLANATION OF THE 2,138
CLINICAL RATIONALE FOR THE DECISION.
(E) THE INDEPENDENT REVIEW ORGANIZATION SHALL BASE ITS 2,140
DECISION ON THE INFORMATION SUBMITTED UNDER DIVISION (D)(8) OF 2,141
THIS SECTION. IN MAKING ITS DECISION, THE INDEPENDENT REVIEW 2,142
ORGANIZATION SHALL CONSIDER SAFETY, EFFICACY, APPROPRIATENESS, 2,143
AND COST-EFFECTIVENESS.
(F) THE INSURER SHALL PROVIDE ANY COVERAGE DETERMINED BY 2,145
THE INDEPENDENT REVIEW ORGANIZATION'S DECISION TO BE MEDICALLY 2,146
NECESSARY, SUBJECT TO THE OTHER TERMS, LIMITATIONS, AND 2,147
CONDITIONS OF THE INSURED'S POLICY OR CERTIFICATE. 2,148
Sec. 3923.68. (A) EACH INSURER SHALL ESTABLISH A 2,150
REASONABLE EXTERNAL, INDEPENDENT REVIEW PROCESS TO EXAMINE THE 2,152
INSURER'S COVERAGE DECISIONS FOR INSUREDS WHO MEET ALL OF THE 2,153
FOLLOWING CRITERIA: 2,154
(1) THE INSURED HAS A TERMINAL CONDITION THAT, ACCORDING 2,156
TO THE CURRENT DIAGNOSIS OF THE INSURED'S PHYSICIAN, HAS A HIGH 2,157
PROBABILITY OF CAUSING DEATH WITHIN TWO YEARS. 2,158
(2) THE INSURED REQUESTS A REVIEW NOT LATER THAN SIXTY 2,160
DAYS AFTER RECEIPT BY THE INSURED OF NOTICE FROM THE 2,161
48
SUPERINTENDENT OF INSURANCE UNDER SECTION 3923.66 OF THE REVISED 2,162
CODE THAT MAKING A DETERMINATION REQUIRES RESOLUTION OF A MEDICAL 2,163
ISSUE.
(3) THE INSURED'S PHYSICIAN CERTIFIES THAT THE INSURED HAS 2,165
THE CONDITION DESCRIBED IN DIVISION (A)(1) OF THIS SECTION AND 2,166
ANY OF THE FOLLOWING SITUATIONS ARE APPLICABLE: 2,167
(a) STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN 2,169
IMPROVING THE CONDITION OF THE INSURED. 2,171
(b) STANDARD THERAPIES ARE NOT MEDICALLY APPROPRIATE FOR 2,173
THE INSURED. 2,175
(c) THERE IS NO STANDARD THERAPY COVERED BY THE INSURER 2,177
THAT IS MORE BENEFICIAL THAN THERAPY DESCRIBED IN DIVISION (A)(4) 2,179
OF THIS SECTION. 2,180
(4) THE INSURED'S PHYSICIAN HAS RECOMMENDED A DRUG, 2,182
DEVICE, PROCEDURE, OR OTHER THERAPY THAT THE PHYSICIAN CERTIFIES, 2,183
IN WRITING, IS LIKELY TO BE MORE BENEFICIAL TO THE INSURED, IN 2,184
THE PHYSICIAN'S OPINION, THAN STANDARD THERAPIES, OR THE INSURED 2,185
HAS REQUESTED A THERAPY THAT HAS BEEN FOUND IN A PREPONDERANCE OF 2,186
PEER-REVIEWED PUBLISHED STUDIES TO BE ASSOCIATED WITH EFFECTIVE 2,187
CLINICAL OUTCOMES FOR THE SAME CONDITION. 2,188
(5) THE INSURED HAS BEEN DENIED COVERAGE BY THE INSURER 2,190
FOR A DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY RECOMMENDED OR 2,191
REQUESTED PURSUANT TO DIVISION (A)(4) OF THIS SECTION, AND HAS 2,192
EXHAUSTED THE INSURER'S INTERNAL REVIEW PROCESS. 2,194
(6) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, FOR 2,196
WHICH COVERAGE HAS BEEN DENIED, WOULD BE A COVERED HEALTH CARE 2,197
SERVICE EXCEPT FOR THE INSURER'S DETERMINATION THAT THE DRUG, 2,198
DEVICE, PROCEDURE, OR OTHER THERAPY IS EXPERIMENTAL OR 2,199
INVESTIGATIONAL.
(B) A REVIEW SHALL BE REQUESTED IN WRITING, EXCEPT THAT IF 2,201
THE INSURED'S PHYSICIAN DETERMINES THAT A THERAPY WOULD BE 2,202
SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, THE 2,204
REVIEW MAY BE REQUESTED ORALLY OR BY ELECTRONIC MEANS. WHEN AN 2,205
ORAL OR ELECTRONIC REQUEST FOR REVIEW IS MADE, WRITTEN 2,206
49
CONFIRMATION OF THE REQUEST SHALL BE SUBMITTED TO THE INSURER NOT 2,207
LATER THAN FIVE DAYS AFTER THE ORAL OR WRITTEN REQUEST IS
SUBMITTED. 2,208
(C) THE EXTERNAL, INDEPENDENT REVIEW PROCESS ESTABLISHED 2,210
BY AN INSURER SHALL MEET ALL OF THE FOLLOWING CRITERIA: 2,211
(1) EXCEPT AS PROVIDED IN DIVISION (E) OF THIS SECTION, 2,213
THE PROCESS SHALL AFFORD ALL INSUREDS WHO MEET THE CRITERIA SET 2,214
FORTH IN DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE THE 2,215
INSURER'S DECISION TO DENY COVERAGE OF THE RECOMMENDED OR 2,216
REQUESTED THERAPY REVIEWED UNDER THE PROCESS. EACH ELIGIBLE 2,218
INSURED SHALL BE NOTIFIED OF THAT OPPORTUNITY WITHIN THIRTY 2,219
BUSINESS DAYS AFTER THE INSURER DENIES COVERAGE. 2,220
(2) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 2,222
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 2,223
SECTION 3901.80 OF THE REVISED CODE. 2,224
THE INDEPENDENT REVIEW ORGANIZATION SHALL SELECT A PANEL TO 2,227
CONDUCT THE REVIEW, WHICH PANEL SHALL BE COMPOSED OF AT LEAST 2,228
THREE PHYSICIANS OR OTHER PROVIDERS WHO, THROUGH CLINICAL 2,229
EXPERIENCE IN THE PAST THREE YEARS, ARE EXPERTS IN THE TREATMENT 2,230
OF THE INSURED'S MEDICAL CONDITION AND KNOWLEDGEABLE ABOUT THE 2,231
RECOMMENDED OR REQUESTED THERAPY. 2,232
IN EITHER OF THE FOLLOWING CIRCUMSTANCES, AN EXCEPTION MAY 2,234
BE MADE TO THE REQUIREMENT THAT THE REVIEW BE CONDUCTED BY AN 2,235
EXPERT PANEL COMPOSED OF A MINIMUM OF THREE PHYSICIANS OR OTHER 2,236
PROVIDERS:
(a) A REVIEW MAY BE CONDUCTED BY AN EXPERT PANEL COMPOSED 2,238
OF ONLY TWO PHYSICIANS OR OTHER PROVIDERS IF AN INSURED HAS 2,240
CONSENTED IN WRITING TO A REVIEW BY THE SMALLER PANEL. 2,242
(b) A REVIEW MAY BE CONDUCTED BY A SINGLE EXPERT PHYSICIAN 2,244
OR OTHER PROVIDER IF ONLY THE EXPERT PHYSICIAN OR OTHER PROVIDER 2,246
IS AVAILABLE FOR THE REVIEW. 2,247
(3) NEITHER THE INSURER NOR THE INSURED SHALL CHOOSE, OR 2,249
CONTROL THE CHOICE OF, THE PHYSICIAN OR OTHER PROVIDER EXPERTS. 2,250
(4) THE SELECTED EXPERTS, ANY HEALTH CARE FACILITY WITH 2,252
50
WHICH AN EXPERT IS AFFILIATED, AND THE INDEPENDENT REVIEW 2,253
ORGANIZATION ARRANGING FOR THE EXPERTS' REVIEW SHALL NOT HAVE ANY 2,254
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 2,255
FOLLOWING:
(a) THE INSURER OR ANY OFFICER, DIRECTOR, OR MANAGERIAL 2,257
EMPLOYEE OF THE INSURER; 2,259
(b) THE INSURED, THE INSURED'S PHYSICIAN, OR THE PRACTICE 2,261
GROUP OF THE INSURED'S PHYSICIAN; 2,263
(c) THE HEALTH CARE FACILITY AT WHICH THE RECOMMENDED OR 2,265
REQUESTED THERAPY WOULD BE PROVIDED; 2,267
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 2,269
DEVICE, PROCEDURE, OR THERAPY INVOLVED IN THE RECOMMENDED OR 2,271
REQUESTED THERAPY.
HOWEVER, EXPERTS AFFILIATED WITH ACADEMIC MEDICAL CENTERS 2,274
WHO PROVIDE HEALTH CARE SERVICES TO INSUREDS OF THE INSURER MAY 2,276
SERVE AS EXPERTS ON THE REVIEW PANEL. FURTHER, EXPERTS WITH STAFF 2,277
PRIVILEGES AT A HEALTH CARE FACILITY THAT PROVIDES HEALTH CARE 2,278
SERVICES TO INSUREDS OF THE INSURER, AS WELL AS EXPERTS WHO HAVE 2,279
A CONTRACTUAL RELATIONSHIP WITH THE INSURER, BUT WHO WERE NOT 2,280
INVOLVED WITH THE INSURER'S DENIAL OF COVERAGE FOR THE THERAPY 2,281
UNDER REVIEW, MAY SERVE AS EXPERTS ON THE REVIEW PANEL. THESE 2,282
NONAFFILIATION PROVISIONS DO NOT PRECLUDE AN INSURER FROM PAYING 2,283
FOR THE EXPERTS' REVIEW, AS SPECIFIED IN DIVISION (C)(5) OF THIS 2,284
SECTION.
(5) INSUREDS SHALL NOT BE REQUIRED TO PAY FOR ANY PART OF 2,286
THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE BY 2,287
THE INSURER. 2,288
(6) THE INSURER SHALL PROVIDE TO THE INDEPENDENT REVIEW 2,290
ORGANIZATION ARRANGING FOR THE EXPERTS' REVIEW A COPY OF THOSE 2,291
RECORDS IN THE INSURER'S POSSESSION THAT ARE RELEVANT TO THE 2,292
INSURED'S MEDICAL CONDITION AND THE REVIEW. THE RECORDS SHALL BE 2,293
DISCLOSED SOLELY TO THE EXPERT REVIEWERS AND SHALL BE USED SOLELY 2,294
FOR THE PURPOSE OF THIS SECTION. AT THE REQUEST OF THE EXPERT 2,295
REVIEWERS, THE INSURER OR THE PHYSICIAN REQUESTING THE THERAPY 2,296
51
SHALL PROVIDE ANY ADDITIONAL INFORMATION THAT THE EXPERT 2,297
REVIEWERS REQUEST TO COMPLETE THE REVIEW. AN EXPERT REVIEWER IS 2,298
NOT REQUIRED TO RENDER AN OPINION IF THE REVIEWER HAS NOT 2,299
RECEIVED ANY REQUESTED INFORMATION THAT THE REVIEWER CONSIDERS 2,300
NECESSARY TO COMPLETE THE REVIEW.
(7)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 2,302
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 2,303
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 2,307
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 2,310
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 2,311
COPY OF ITS DECISION TO THE INSURER AND THE INSURED. IF THE 2,312
INSURED'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING HEALTH 2,313
CARE SERVICES TO THE INSURED REQUESTED THE REVIEW, THE 2,314
INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A COPY OF ITS 2,316
DECISION TO THE INSURED'S PROVIDER OR THE HEALTH CARE FACILITY. 2,317
(b) IN CONDUCTING THE REVIEW, THE EXPERTS ON THE PANEL 2,319
SHALL TAKE INTO ACCOUNT ALL OF THE FOLLOWING: 2,320
(i) INFORMATION SUBMITTED BY THE INSURER, THE INSURED, AND 2,323
THE INSURED'S PHYSICIAN, INCLUDING THE INSURED'S MEDICAL RECORDS 2,324
AND THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED BY THE 2,325
INSURER TO REACH ITS COVERAGE DECISION; 2,326
(ii) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 2,328
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 2,329
ORGANIZATIONS;
(iii) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 2,331
SCIENTIFIC LITERATURE AND PUBLISHED OPINIONS OF NATIONALLY 2,332
RECOGNIZED MEDICAL EXPERTS; 2,333
(iv) CLINICAL GUIDELINES ADOPTED BY RELEVANT NATIONAL 2,335
MEDICAL SOCIETIES; 2,336
(v) SAFETY, EFFICACY, APPROPRIATENESS, AND COST 2,338
EFFECTIVENESS.
(8) EACH EXPERT ON THE PANEL SHALL PROVIDE THE INDEPENDENT 2,341
REVIEW ORGANIZATION WITH A PROFESSIONAL OPINION AS TO WHETHER 2,342
52
THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE RECOMMENDED 2,343
OR REQUESTED THERAPY IS LIKELY TO BE MORE BENEFICIAL TO THE 2,344
INSURED THAN STANDARD THERAPIES. 2,345
(9) EACH EXPERT'S OPINION SHALL BE PRESENTED IN WRITTEN 2,347
FORM AND SHALL INCLUDE THE FOLLOWING INFORMATION: 2,348
(a) A DESCRIPTION OF THE INSURED'S CONDITION; 2,350
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO 2,352
DETERMINING WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE 2,354
THAT THE RECOMMENDED OR REQUESTED THERAPY IS MORE LIKELY THAN NOT 2,356
TO BE MORE BENEFICIAL TO THE INSURED THAN STANDARD THERAPIES; 2,358
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS 2,360
PUBLISHED IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR 2,362
THE PUBLISHED OPINIONS OF MEDICAL EXPERTS OR SPECIALTY SOCIETIES; 2,364
(d) A DESCRIPTION OF THE INSURED'S SUITABILITY TO RECEIVE 2,366
THE RECOMMENDED OR REQUESTED THERAPY ACCORDING TO A TREATMENT 2,368
PROTOCOL IN A CLINICAL TRIAL, IF APPLICABLE. 2,370
(10) THE INDEPENDENT REVIEW ORGANIZATION SHALL PROVIDE THE 2,372
INSURER WITH THE OPINIONS OF THE EXPERTS. THE INSURER SHALL MAKE 2,373
THE EXPERTS' OPINIONS AVAILABLE TO THE INSURED AND THE INSURED'S 2,374
PHYSICIAN, UPON REQUEST. 2,375
(11) THE OPINION OF THE MAJORITY OF THE EXPERTS ON THE 2,377
PANEL, RENDERED PURSUANT TO DIVISION (C)(8) OF THIS SECTION, IS 2,378
BINDING ON THE INSURER WITH RESPECT TO THAT INSURED. IF THE 2,379
OPINIONS OF THE EXPERTS ON THE PANEL ARE EVENLY DIVIDED AS TO 2,381
WHETHER THE THERAPY SHOULD BE COVERED, THE INSURER'S FINAL 2,382
DECISION SHALL BE IN FAVOR OF COVERAGE. IF LESS THAN A MAJORITY 2,383
OF THE EXPERTS ON THE PANEL RECOMMEND COVERAGE OF THE THERAPY, 2,384
THE INSURER MAY, IN ITS DISCRETION, COVER THE THERAPY. HOWEVER, 2,385
ANY COVERAGE PROVIDED PURSUANT TO DIVISION (C)(11) OF THIS 2,386
SECTION IS SUBJECT TO THE TERMS, LIMITATIONS, AND CONDITIONS OF 2,387
THE INSURED'S POLICY OR CERTIFICATE WITH THE INSURER. 2,388
(12) THE INSURER SHALL HAVE WRITTEN POLICIES DESCRIBING 2,390
THE EXTERNAL, INDEPENDENT REVIEW PROCESS. 2,391
(D) IF AN INSURER'S INITIAL DENIAL OF COVERAGE FOR A 2,393
53
THERAPY RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF 2,394
THIS SECTION IS BASED UPON AN EXTERNAL, INDEPENDENT REVIEW OF 2,395
THAT THERAPY MEETING THE REQUIREMENTS OF DIVISION (C) OF THIS 2,397
SECTION, THIS SECTION SHALL NOT BE A BASIS FOR REQUIRING A SECOND 2,398
EXTERNAL, INDEPENDENT REVIEW OF THE RECOMMENDED OR REQUESTED 2,399
THERAPY.
(E) AT ANY TIME DURING THE EXTERNAL, INDEPENDENT REVIEW 2,401
PROCESS, THE INSURER MAY ELECT TO COVER THE RECOMMENDED OR 2,402
REQUESTED HEALTH CARE SERVICE AND TERMINATE THE REVIEW. THE 2,404
INSURER SHALL NOTIFY THE INSURED AND ALL OTHER PARTIES INVOLVED 2,405
BY MAIL OR, WITH CONSENT OR APPROVAL OF THE INSURED, BY
ELECTRONIC MEANS. 2,406
(F) THE INSURER SHALL ANNUALLY FILE A CERTIFICATE WITH THE 2,408
SUPERINTENDENT OF INSURANCE CERTIFYING ITS COMPLIANCE WITH THE 2,409
REQUIREMENTS OF THIS SECTION. 2,410
Sec. 3923.681. (A) IF, AFTER NOTICE AND HEARING, THE 2,412
SUPERINTENDENT OF INSURANCE FINDS THAT AN INSURER HAS FAILED TO 2,414
COMPLY WITH SECTION 3923.66 OR 3923.67 OF THE REVISED CODE, THE 2,415
SUPERINTENDENT MAY SUSPEND OR REVOKE THE INSURER'S LICENSE TO 2,416
TRANSACT BUSINESS WITHIN THE STATE.
(B)(1) IN LIEU OF THE SUSPENSION OR REVOCATION OF A 2,419
LICENSE UNDER DIVISION (A) OF THIS SECTION, THE SUPERINTENDENT OF 2,420
INSURANCE, PURSUANT TO AN ADJUDICATION HEARING INITIATED AND 2,421
CONDUCTED IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, OR 2,423
BY CONSENT OF THE INSURER WITHOUT AN ADJUDICATION HEARING, MAY 2,424
LEVY AN ADMINISTRATIVE PENALTY. THE ADMINISTRATIVE PENALTY SHALL 2,425
BE IN AN AMOUNT DETERMINED BY THE SUPERINTENDENT, BUT THE 2,427
ADMINISTRATIVE PENALTY SHALL NOT EXCEED ONE HUNDRED THOUSAND 2,428
DOLLARS PER VIOLATION. ADDITIONALLY, THE SUPERINTENDENT MAY 2,429
REQUIRE THE INSURER TO CORRECT ANY DEFICIENCY THAT MAY BE THE 2,431
BASIS FOR THE SUSPENSION OR REVOCATION OF THE INSURER'S LICENSE. 2,432
ALL PENALTIES COLLECTED SHALL BE PAID INTO THE STATE TREASURY TO 2,434
THE CREDIT OF THE DEPARTMENT OF INSURANCE OPERATING FUND. 2,435
(2) IF THE SUPERINTENDENT FOR ANY REASON HAS CAUSE TO 2,439
54
BELIEVE THAT ANY VIOLATION OF SECTION 3923.66 OR 3923.67 OF THE
REVISED CODE HAS OCCURRED OR IS THREATENED, THE SUPERINTENDENT 2,441
MAY GIVE NOTICE TO THE INSURER AND TO THE REPRESENTATIVES OR 2,443
OTHER PERSONS WHO APPEAR TO BE INVOLVED IN THE SUSPECTED 2,444
VIOLATION TO ARRANGE A CONFERENCE WITH THE SUSPECTED VIOLATORS OR 2,445
THEIR AUTHORIZED REPRESENTATIVES FOR THE PURPOSE OF ATTEMPTING TO 2,446
ASCERTAIN THE FACTS RELATING TO THE SUSPECTED VIOLATION, AND, IF 2,447
IT APPEARS THAT ANY VIOLATION HAS OCCURRED OR IS THREATENED, TO 2,448
ARRIVE AT AN ADEQUATE AND EFFECTIVE MEANS OF CORRECTING OR 2,449
PREVENTING THE VIOLATION.
PROCEEDINGS SHALL NOT BE COVERED BY ANY FORMAL PROCEDURAL 2,452
REQUIREMENTS, AND MAY BE CONDUCTED IN THE MANNER THE 2,453
SUPERINTENDENT MAY CONSIDER APPROPRIATE UNDER THE CIRCUMSTANCES. 2,454
(3)(a) THE SUPERINTENDENT MAY ISSUE AN ORDER DIRECTING AN 2,456
INSURER OR A REPRESENTATIVE OF THE INSURER TO CEASE AND DESIST 2,457
FROM ENGAGING IN ANY ACT OR PRACTICE IN VIOLATION OF SECTION 2,459
3923.67 OR 3923.68 OF THE REVISED CODE. WITHIN THIRTY DAYS AFTER 2,460
SERVICE OF THE ORDER TO CEASE AND DESIST, THE RESPONDENT MAY 2,461
REQUEST A HEARING ON THE QUESTION OF WHETHER ACTS OR PRACTICES IN 2,463
VIOLATION OF THOSE SECTIONS HAVE OCCURRED. SUCH HEARINGS SHALL
BE CONDUCTED IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE 2,465
AND JUDICIAL REVIEW SHALL BE AVAILABLE AS PROVIDED BY THAT 2,466
CHAPTER.
(b) IF THE SUPERINTENDENT HAS REASONABLE CAUSE TO BELIEVE 2,468
THAT AN ORDER HAS BEEN VIOLATED IN WHOLE OR IN PART, THE 2,470
SUPERINTENDENT MAY REQUEST THE ATTORNEY GENERAL TO COMMENCE AND 2,471
PROSECUTE ANY APPROPRIATE ACTION OR PROCEEDING IN THE NAME OF THE 2,472
STATE AGAINST THE VIOLATORS IN THE COURT OF COMMON PLEAS OF 2,474
FRANKLIN COUNTY. THE COURT IN ANY SUCH ACTION OR PROCEEDING MAY 2,475
LEVY CIVIL PENALTIES, NOT TO EXCEED ONE HUNDRED THOUSAND DOLLARS 2,476
PER VIOLATION, IN ADDITION TO ANY OTHER APPROPRIATE RELIEF, 2,477
INCLUDING REQUIRING A VIOLATOR TO PAY THE EXPENSES REASONABLY 2,478
INCURRED BY THE SUPERINTENDENT IN ENFORCING THE ORDER. THE 2,479
PENALTIES AND FEES COLLECTED SHALL BE PAID INTO THE STATE 2,480
55
TREASURY TO THE CREDIT OF THE DEPARTMENT OF INSURANCE OPERATING 2,481
FUND.
Sec. 3923.69. NOTHING IN SECTIONS 3923.66 TO 3923.68 OF 2,483
THE REVISED CODE SHALL BE CONSTRUED TO CREATE A CAUSE OF ACTION 2,485
AGAINST ANY OF THE FOLLOWING:
(A) AN EMPLOYER THAT PROVIDES HEALTH CARE BENEFITS TO 2,489
EMPLOYEES THROUGH AN INSURER;
(B) A CLINICAL PEER OR INDEPENDENT REVIEW ORGANIZATION 2,492
THAT PARTICIPATES IN AN EXTERNAL REVIEW UNDER SECTION 3923.67 OR 2,493
3923.68 OF THE REVISED CODE; 2,494
(C) AN INSURER THAT PROVIDES COVERAGE FOR BENEFITS 2,498
PURSUANT TO SECTION 3923.67 OR 3923.68 OF THE REVISED CODE. 2,499
Sec. 3923.70. CONSISTENT WITH THE RULES OF EVIDENCE, A 2,502
WRITTEN DECISION OR OPINION PREPARED BY AN INDEPENDENT REVIEW 2,503
ORGANIZATION UNDER SECTION 3923.67 OR 3923.68 OF THE REVISED CODE 2,504
SHALL BE ADMISSIBLE IN ANY CIVIL ACTION RELATED TO THE COVERAGE 2,505
DECISION THAT WAS THE SUBJECT OF THE DECISION OR OPINION. THE 2,506
INDEPENDENT REVIEW ORGANIZATION'S DECISION OR OPINION SHALL BE 2,507
PRESUMED TO BE A SCIENTIFICALLY VALID AND ACCURATE DESCRIPTION OF 2,508
THE STATE OF MEDICAL KNOWLEDGE AT THE TIME IT WAS WRITTEN. 2,509
CONSISTENT WITH THE RULES OF EVIDENCE, ANY PARTY TO A CIVIL 2,512
ACTION RELATED TO AN INSURER'S DECISION INVOLVING AN 2,513
INVESTIGATIONAL OR EXPERIMENTAL DRUG, DEVICE, OR TREATMENT MAY
INTRODUCE INTO EVIDENCE ANY APPLICABLE MEDICARE REIMBURSEMENT 2,514
STANDARDS ESTABLISHED UNDER TITLE XVIII OF THE "SOCIAL SECURITY 2,516
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED. 2,517
Sec. 3923.75. (A) AS USED IN SECTIONS 3923.75 TO 3923.79 2,519
OF THE REVISED CODE: 2,520
(1) "CLINICAL PEER" AND "PHYSICIAN" HAVE THE SAME MEANINGS 2,522
AS IN SECTION 1751.77 OF THE REVISED CODE. 2,523
(2) "AUTHORIZED PERSON" MEANS A PARENT, GUARDIAN, OR OTHER 2,525
PERSON AUTHORIZED TO ACT ON BEHALF OF A PLAN MEMBER WITH RESPECT 2,526
TO HEALTH CARE DECISIONS. 2,527
(B) SECTIONS 3923.75 TO 3923.79 OF THE REVISED CODE DO NOT 2,529
56
APPLY TO ANY PUBLIC EMPLOYEE BENEFIT PLAN COVERING ONLY ACCIDENT, 2,531
CREDIT, DENTAL, DISABILITY INCOME, LONG-TERM CARE, HOSPITAL 2,532
INDEMNITY, MEDICARE SUPPLEMENT, MEDICARE, TRICARE, SPECIFIED 2,533
DISEASE, OR VISION CARE; COVERAGE ISSUED AS A SUPPLEMENT TO 2,534
LIABILITY INSURANCE; INSURANCE ARISING OUT OF WORKERS' 2,535
COMPENSATION OR SIMILAR LAW; AUTOMOBILE MEDICAL PAYMENT 2,536
INSURANCE; OR INSURANCE UNDER WHICH BENEFITS ARE PAYABLE WITH OR 2,537
WITHOUT REGARD TO FAULT AND WHICH IS STATUTORILY REQUIRED TO BE 2,538
CONTAINED IN ANY LIABILITY INSURANCE POLICY OR EQUIVALENT 2,539
SELF-INSURANCE.
(C) THE SUPERINTENDENT OF INSURANCE SHALL ESTABLISH AND 2,541
MAINTAIN A SYSTEM FOR RECEIVING AND REVIEWING REQUESTS FOR REVIEW 2,543
FROM PLAN MEMBERS WHO HAVE BEEN DENIED COVERAGE OF A HEALTH CARE 2,544
SERVICE ON THE GROUNDS THAT THE SERVICE IS NOT A SERVICE COVERED 2,545
UNDER THE TERMS OF THE PUBLIC EMPLOYEE BENEFIT PLAN. 2,546
ON RECEIPT OF A WRITTEN REQUEST FROM A PLAN MEMBER OR 2,548
AUTHORIZED PERSON, THE SUPERINTENDENT SHALL CONSIDER WHETHER THE 2,549
HEALTH CARE SERVICE IS A SERVICE COVERED UNDER THE TERMS OF THE 2,550
PLAN, EXCEPT THAT THE SUPERINTENDENT SHALL NOT CONDUCT A REVIEW 2,552
UNDER THIS SECTION UNLESS THE PLAN MEMBER HAS EXHAUSTED THE 2,553
PLAN'S INTERNAL REVIEW PROCESS. THE PLAN AND THE PLAN MEMBER OR 2,554
AUTHORIZED PERSON SHALL PROVIDE THE SUPERINTENDENT WITH ANY 2,555
INFORMATION REQUIRED BY THE SUPERINTENDENT THAT IS IN THEIR 2,556
POSSESSION AND IS GERMANE TO THE REVIEW.
UNLESS THE SUPERINTENDENT IS NOT ABLE TO DO SO BECAUSE 2,558
MAKING THE DETERMINATION REQUIRES RESOLUTION OF A MEDICAL ISSUE, 2,559
THE SUPERINTENDENT SHALL DETERMINE WHETHER THE HEALTH CARE 2,560
SERVICE AT ISSUE IS A SERVICE COVERED UNDER THE TERMS OF THE 2,561
PLAN. THE SUPERINTENDENT SHALL NOTIFY THE PLAN MEMBER AND THE 2,562
PLAN OF ITS DETERMINATION OR THAT IT IS NOT ABLE TO MAKE A 2,563
DETERMINATION BECAUSE THE DETERMINATION REQUIRES THE RESOLUTION 2,564
OF A MEDICAL ISSUE.
IF THE SUPERINTENDENT NOTIFIES THE PLAN THAT MAKING THE 2,566
DETERMINATION REQUIRES THE RESOLUTION OF A MEDICAL ISSUE, THE 2,567
57
PLAN SHALL AFFORD THE PLAN MEMBER AN OPPORTUNITY FOR EXTERNAL 2,568
REVIEW UNDER SECTION 3923.76 OR 3923.77 OF THE REVISED CODE. IF 2,569
THE SUPERINTENDENT NOTIFIES THE PLAN THAT THE HEALTH CARE SERVICE 2,570
IS NOT A COVERED SERVICE, THE PLAN IS NOT REQUIRED TO COVER THE 2,571
SERVICE OR AFFORD THE PLAN MEMBER AN EXTERNAL REVIEW. 2,572
Sec. 3923.76. (A) EXCEPT AS PROVIDED IN DIVISIONS (B) AND 2,575
(C) OF THIS SECTION, A PUBLIC EMPLOYEE BENEFIT PLAN SHALL AFFORD 2,576
A PLAN MEMBER AN OPPORTUNITY FOR AN EXTERNAL REVIEW OF A 2,578
COVERAGE DENIAL WHEN REQUESTED BY THE PLAN MEMBER OR AUTHORIZED 2,579
PERSON, IF BOTH OF THE FOLLOWING ARE THE CASE:
(1) THE PLAN HAS DENIED, REDUCED, OR TERMINATED COVERAGE 2,581
FOR WHAT WOULD BE A COVERED HEALTH CARE SERVICE EXCEPT THAT THE 2,582
PLAN HAS DETERMINED THAT THE HEALTH CARE SERVICE IS NOT MEDICALLY 2,583
NECESSARY.
(2) EXCEPT IN THE CASE OF EXPEDITED REVIEW, THE PROPOSED 2,586
SERVICE, PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL 2,587
COST THE PLAN MEMBER MORE THAN FIVE HUNDRED DOLLARS IF THE 2,588
PROPOSED SERVICE IS NOT COVERED BY THE PLAN. 2,589
EXTERNAL REVIEW SHALL BE CONDUCTED IN ACCORDANCE WITH THIS 2,591
SECTION, EXCEPT THAT IF A PLAN MEMBER WITH A TERMINAL CONDITION 2,592
MEETS ALL OF THE CRITERIA OF DIVISION (A) OF SECTION 3923.77 OF 2,593
THE REVISED CODE, AN EXTERNAL REVIEW SHALL BE CONDUCTED UNDER 2,595
THAT SECTION. 2,596
(B) A PLAN MEMBER NEED NOT BE AFFORDED A REVIEW UNDER THIS 2,598
SECTION IN ANY OF THE FOLLOWING CIRCUMSTANCES: 2,600
(1) THE SUPERINTENDENT OF INSURANCE HAS DETERMINED UNDER 2,602
SECTION 3923.75 OF THE REVISED CODE THAT THE HEALTH CARE SERVICE 2,603
IS NOT A SERVICE COVERED UNDER THE TERMS OF THE PLAN. 2,604
(2) THE PLAN MEMBER HAS FAILED TO EXHAUST THE PLAN'S 2,606
INTERNAL REVIEW PROCESS. 2,607
(3) THE PLAN MEMBER HAS PREVIOUSLY BEEN AFFORDED AN 2,609
EXTERNAL REVIEW FOR THE SAME DENIAL OF COVERAGE, AND NO NEW 2,610
CLINICAL INFORMATION HAS BEEN SUBMITTED TO THE PLAN. 2,611
(C)(1) A PLAN MAY DENY A REQUEST FOR AN EXTERNAL REVIEW IF 2,613
58
IT IS REQUESTED LATER THAN SIXTY DAYS AFTER RECEIPT BY THE PLAN 2,614
MEMBER OF NOTICE FROM THE SUPERINTENDENT OF INSURANCE UNDER 2,615
SECTION 3923.75 OF THE REVISED CODE THAT MAKING THE DETERMINATION 2,616
REQUIRES THE RESOLUTION OF A MEDICAL ISSUE. AN EXTERNAL REVIEW 2,618
MAY BE REQUESTED BY THE PLAN MEMBER, AN AUTHORIZED PERSON, THE 2,619
PLAN MEMBER'S PROVIDER, OR A HEALTH CARE FACILITY RENDERING 2,620
HEALTH CARE SERVICE TO THE PLAN MEMBER. THE PLAN MEMBER MAY 2,621
REQUEST A REVIEW WITHOUT THE APPROVAL OF THE PROVIDER OR THE 2,622
HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE. THE 2,623
PROVIDER OR HEALTH CARE FACILITY MAY NOT REQUEST A REVIEW WITHOUT 2,624
THE PRIOR CONSENT OF THE PLAN MEMBER.
(2) AN EXTERNAL REVIEW MUST BE REQUESTED IN WRITING, 2,626
EXCEPT THAT IF THE PLAN MEMBER HAS A CONDITION THAT REQUIRES 2,627
EXPEDITED REVIEW, THE REVIEW MAY BE REQUESTED ORALLY OR BY 2,628
ELECTRONIC MEANS. WHEN AN ORAL OR ELECTRONIC REQUEST FOR REVIEW 2,629
IS MADE, WRITTEN CONFIRMATION OF THE REQUEST MUST BE SUBMITTED TO 2,630
THE PLAN NOT LATER THAN FIVE DAYS AFTER THE REQUEST IS MADE. 2,631
EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, A REQUEST FOR AN 2,633
EXTERNAL REVIEW MUST BE ACCOMPANIED BY WRITTEN CERTIFICATION FROM 2,634
THE PLAN MEMBER'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING 2,635
THE HEALTH CARE SERVICE TO THE PLAN MEMBER THAT THE PROPOSED 2,636
SERVICE, PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL 2,637
COST THE PLAN MEMBER MORE THAN FIVE HUNDRED DOLLARS IF THE 2,638
PROPOSED SERVICE IS NOT COVERED BY THE PLAN. 2,639
(3) FOR AN EXPEDITED REVIEW, THE PLAN MEMBER'S PROVIDER 2,641
MUST CERTIFY THAT THE PLAN MEMBER'S CONDITION COULD, IN THE 2,642
ABSENCE OF IMMEDIATE MEDICAL ATTENTION, RESULT IN ANY OF THE 2,643
FOLLOWING:
(a) PLACING THE HEALTH OF THE PLAN MEMBER OR, WITH RESPECT 2,645
TO A PREGNANT WOMAN, THE HEALTH OF THE PLAN MEMBER OR THE UNBORN 2,647
CHILD, IN SERIOUS JEOPARDY; 2,648
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,650
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,652
(D) THE PROCEDURES USED IN CONDUCTING AN EXTERNAL REVIEW 2,654
59
SHALL INCLUDE ALL OF THE FOLLOWING: 2,655
(1) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 2,657
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 2,658
SECTION 3901.80 OF THE REVISED CODE. 2,659
(2) EXCEPT AS PROVIDED IN DIVISIONS (D)(3) AND (4) OF THIS 2,661
SECTION, NEITHER THE CLINICAL PEER NOR ANY HEALTH CARE FACILITY 2,662
WITH WHICH THE CLINICAL PEER IS AFFILIATED SHALL HAVE ANY 2,663
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 2,664
FOLLOWING: 2,665
(a) THE PLAN OR ANY OFFICER, DIRECTOR, OR MANAGERIAL 2,667
EMPLOYEE OF THE PLAN; 2,669
(b) THE PLAN MEMBER, THE PLAN MEMBER'S PROVIDER, OR THE 2,671
PRACTICE GROUP OF THE PLAN MEMBER'S PROVIDER; 2,673
(c) THE HEALTH CARE FACILITY AT WHICH THE HEALTH CARE 2,675
SERVICE REQUESTED BY THE PLAN MEMBER WOULD BE PROVIDED; 2,677
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 2,679
DEVICE, PROCEDURE, OR THERAPY PROPOSED FOR THE PLAN MEMBER. 2,681
(3) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT A 2,683
CLINICAL PEER FROM CONDUCTING A REVIEW UNDER ANY OF THE FOLLOWING 2,684
CIRCUMSTANCES: 2,685
(a) THE CLINICAL PEER IS AFFILIATED WITH AN ACADEMIC 2,687
MEDICAL CENTER THAT PROVIDES HEALTH CARE SERVICES TO MEMBERS OF 2,689
THE PLAN. 2,690
(b) THE CLINICAL PEER HAS STAFF PRIVILEGES AT A HEALTH 2,692
CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO MEMBERS OF 2,694
THE PLAN. 2,695
(c) THE CLINICAL PEER HAS A CONTRACTUAL RELATIONSHIP WITH 2,697
THE PLAN BUT WAS NOT INVOLVED WITH THE PLAN'S COVERAGE DECISION. 2,699
(4) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT THE 2,701
PLAN FROM PAYING THE INDEPENDENT REVIEW ORGANIZATION FOR THE 2,702
CONDUCT OF THE REVIEW. 2,703
(5) A PLAN MEMBER SHALL NOT BE REQUIRED TO PAY FOR ANY 2,705
PART OF THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE 2,706
BORNE BY THE PLAN. 2,707
60
(6)(a) THE PLAN SHALL PROVIDE TO THE INDEPENDENT REVIEW 2,709
ORGANIZATION CONDUCTING THE REVIEW A COPY OF THOSE RECORDS IN ITS 2,711
POSSESSION THAT ARE RELEVANT TO THE PLAN MEMBER'S MEDICAL 2,712
CONDITION AND THE REVIEW. 2,713
RECORDS SHALL BE USED SOLELY FOR THE PURPOSE OF THIS 2,716
DIVISION. AT THE REQUEST OF THE INDEPENDENT REVIEW ORGANIZATION, 2,717
THE PLAN, PLAN MEMBER, PROVIDER, OR HEALTH CARE FACILITY 2,718
RENDERING HEALTH CARE SERVICES TO THE PLAN MEMBER SHALL PROVIDE 2,719
ANY ADDITIONAL INFORMATION THE INDEPENDENT REVIEW ORGANIZATION 2,720
REQUESTS TO COMPLETE THE REVIEW. A REQUEST FOR ADDITIONAL
INFORMATION MAY BE MADE IN WRITING, ORALLY, OR BY ELECTRONIC 2,721
MEANS. THE INDEPENDENT REVIEW ORGANIZATION SHALL SUBMIT THE 2,722
REQUEST TO THE PLAN MEMBER AND THE PLAN. IF A REQUEST IS 2,723
SUBMITTED ORALLY OR BY ELECTRONIC MEANS TO A PLAN MEMBER OR PLAN, 2,724
NOT LATER THAN FIVE DAYS AFTER THE REQUEST IS SUBMITTED, THE 2,725
INDEPENDENT REVIEW ORGANIZATION SHALL PROVIDE WRITTEN 2,726
CONFIRMATION OF THE REQUEST. IF THE REVIEW WAS INITIATED BY A 2,727
PROVIDER OR HEALTH CARE FACILITY, A COPY OF THE REQUEST SHALL BE 2,728
SUBMITTED TO THE PROVIDER OR HEALTH CARE FACILITY. 2,729
(b) AN INDEPENDENT REVIEW ORGANIZATION IS NOT REQUIRED TO 2,731
MAKE A DECISION IF IT HAS NOT RECEIVED ANY REQUESTED INFORMATION 2,733
THAT IT CONSIDERS NECESSARY TO COMPLETE A REVIEW. AN INDEPENDENT 2,734
REVIEW ORGANIZATION THAT DOES NOT MAKE A DECISION FOR THIS REASON 2,735
SHALL NOTIFY THE PLAN MEMBER AND THE PLAN THAT A DECISION IS NOT 2,737
BEING MADE. THE NOTICE MAY BE MADE IN WRITING, ORALLY, OR BY 2,738
ELECTRONIC MEANS. AN ORAL OR ELECTRONIC NOTICE SHALL BE
CONFIRMED IN WRITING NOT LATER THAN FIVE DAYS AFTER THE ORAL OR 2,739
ELECTRONIC NOTICE IS MADE. IF THE REVIEW WAS INITIATED BY A 2,740
PROVIDER OR HEALTH CARE FACILITY, A COPY OF THE NOTICE SHALL BE 2,741
SUBMITTED TO THE PROVIDER OR HEALTH CARE FACILITY. 2,742
(7) THE PLAN MAY ELECT TO COVER THE SERVICE REQUESTED AND 2,745
TERMINATE THE REVIEW. THE PLAN SHALL NOTIFY THE PLAN MEMBER AND 2,746
ALL OTHER PARTIES INVOLVED WITH THE DECISION BY MAIL, OR WITH THE 2,747
CONSENT OR APPROVAL OF THE PLAN MEMBER, BY ELECTRONIC MEANS. 2,748
61
(8) IN MAKING ITS DECISION, AN INDEPENDENT REVIEW 2,750
ORGANIZATION CONDUCTING THE REVIEW SHALL TAKE INTO ACCOUNT ALL OF 2,751
THE FOLLOWING: 2,752
(a) INFORMATION SUBMITTED BY THE PLAN, THE PLAN MEMBER, 2,754
THE PLAN MEMBER'S PROVIDER, AND THE HEALTH CARE FACILITY 2,756
RENDERING THE HEALTH CARE SERVICE, INCLUDING THE FOLLOWING: 2,757
(i) THE PLAN MEMBER'S MEDICAL RECORDS; 2,759
(ii) THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED 2,761
BY THE PLAN TO MAKE ITS DECISION. 2,763
(b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 2,765
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 2,767
ORGANIZATIONS, INCLUDING THE NATIONAL INSTITUTES OF HEALTH OR ANY 2,768
BOARD RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH, THE 2,769
NATIONAL CANCER INSTITUTE, THE NATIONAL ACADEMY OF SCIENCES, THE 2,770
UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 2,772
FINANCING ADMINISTRATION OF THE UNITED STATES DEPARTMENT OF 2,773
HEALTH AND HUMAN SERVICES, AND THE AGENCY FOR HEALTH CARE POLICY 2,774
AND RESEARCH; 2,775
(c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 2,777
SCIENTIFIC LITERATURE, PUBLISHED OPINIONS OF NATIONALLY 2,779
RECOGNIZED MEDICAL EXPERTS, AND CLINICAL GUIDELINES ADOPTED BY 2,780
RELEVANT NATIONAL MEDICAL SOCIETIES. 2,781
(9)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 2,783
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 2,784
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 2,785
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A 2,786
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 2,787
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 2,788
COPY OF ITS DECISION TO THE PLAN AND THE PLAN MEMBER. IF THE 2,789
PLAN MEMBER'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING 2,790
HEALTH CARE SERVICES TO THE PLAN MEMBER REQUESTED THE REVIEW, THE 2,791
INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A COPY OF ITS 2,792
DECISION TO THE PLAN MEMBER'S PROVIDER OR THE HEALTH CARE 2,793
FACILITY.
62
(b) THE INDEPENDENT REVIEW ORGANIZATION'S DECISION SHALL 2,795
INCLUDE A DESCRIPTION OF THE PLAN MEMBER'S CONDITION AND THE 2,797
PRINCIPAL REASONS FOR THE DECISION AND AN EXPLANATION OF THE 2,799
CLINICAL RATIONALE FOR THE DECISION.
(E) THE INDEPENDENT REVIEW ORGANIZATION SHALL BASE ITS 2,801
DECISION ON THE INFORMATION SUBMITTED UNDER DIVISION (D)(8) OF 2,802
THIS SECTION. IN MAKING ITS DECISION, THE INDEPENDENT REVIEW 2,803
ORGANIZATION SHALL CONSIDER SAFETY, EFFICACY, APPROPRIATENESS, 2,805
AND COST-EFFECTIVENESS.
(F) THE PLAN SHALL PROVIDE ANY COVERAGE DETERMINED BY THE 2,807
INDEPENDENT REVIEW ORGANIZATION'S DECISION TO BE MEDICALLY 2,808
NECESSARY, SUBJECT TO THE OTHER TERMS, LIMITATIONS, AND 2,810
CONDITIONS OF THE PLAN.
Sec. 3923.77. (A) EACH PUBLIC EMPLOYEE BENEFIT PLAN SHALL 2,812
ESTABLISH A REASONABLE EXTERNAL REVIEW PROCESS TO EXAMINE THE 2,814
PLAN'S COVERAGE DECISIONS FOR PLAN MEMBERS WHO MEET ALL OF THE 2,815
FOLLOWING CRITERIA: 2,816
(1) THE PLAN MEMBER HAS A TERMINAL CONDITION THAT, 2,818
ACCORDING TO THE CURRENT DIAGNOSIS OF THE PLAN MEMBER'S 2,819
PHYSICIAN, HAS A HIGH PROBABILITY OF CAUSING DEATH WITHIN TWO 2,820
YEARS.
(2) THE PLAN MEMBER REQUESTS A REVIEW NOT LATER THAN SIXTY 2,822
DAYS AFTER RECEIPT BY THE PLAN MEMBER OF NOTICE FROM THE 2,823
SUPERINTENDENT OF INSURANCE UNDER SECTION 3923.75 OF THE REVISED 2,824
CODE THAT MAKING A DETERMINATION REQUIRES RESOLUTION OF A MEDICAL 2,825
ISSUE.
(3) THE PLAN MEMBER'S PHYSICIAN CERTIFIES THAT THE PLAN 2,827
MEMBER HAS THE CONDITION DESCRIBED IN DIVISION (A)(1) OF THIS 2,828
SECTION AND ANY OF THE FOLLOWING SITUATIONS ARE APPLICABLE: 2,829
(a) STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN 2,831
IMPROVING THE CONDITION OF THE PLAN MEMBER. 2,833
(b) STANDARD THERAPIES ARE NOT MEDICALLY APPROPRIATE FOR 2,835
THE PLAN MEMBER. 2,837
(c) THERE IS NO STANDARD THERAPY COVERED BY THE PLAN THAT 2,839
63
IS MORE BENEFICIAL THAN THERAPY DESCRIBED IN DIVISION (A)(4) OF 2,841
THIS SECTION. 2,842
(4) THE PLAN MEMBER'S PHYSICIAN HAS RECOMMENDED A DRUG, 2,844
DEVICE, PROCEDURE, OR OTHER THERAPY THAT THE PHYSICIAN CERTIFIES, 2,845
IN WRITING, IS LIKELY TO BE MORE BENEFICIAL TO THE PLAN MEMBER, 2,846
IN THE PHYSICIAN'S OPINION, THAN STANDARD THERAPIES, OR THE PLAN 2,847
MEMBER HAS REQUESTED A THERAPY THAT HAS BEEN FOUND IN A 2,848
PREPONDERANCE OF PEER-REVIEWED PUBLISHED STUDIES TO BE ASSOCIATED 2,849
WITH EFFECTIVE CLINICAL OUTCOMES FOR THE SAME CONDITION. 2,850
(5) THE PLAN MEMBER HAS BEEN DENIED COVERAGE BY THE PLAN 2,852
FOR A DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY RECOMMENDED OR 2,853
REQUESTED PURSUANT TO DIVISION (A)(4) OF THIS SECTION, AND HAS 2,854
EXHAUSTED ALL INTERNAL APPEALS. 2,855
(6) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, FOR 2,857
WHICH COVERAGE HAS BEEN DENIED, WOULD BE A COVERED HEALTH CARE 2,858
SERVICE EXCEPT FOR THE PLAN'S DETERMINATION THAT THE DRUG, 2,859
DEVICE, PROCEDURE, OR OTHER THERAPY IS EXPERIMENTAL OR 2,860
INVESTIGATIONAL.
(B) A REVIEW SHALL BE REQUESTED IN WRITING, EXCEPT THAT IF 2,862
THE PLAN MEMBER'S PHYSICIAN DETERMINES THAT A THERAPY WOULD BE 2,863
SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, THE 2,865
REVIEW MAY BE REQUESTED ORALLY OR BY ELECTRONIC MEANS. WHEN AN 2,866
ORAL OR ELECTRONIC REQUEST FOR REVIEW IS MADE, WRITTEN 2,867
CONFIRMATION OF THE REQUEST SHALL BE SUBMITTED TO THE PLAN NOT 2,868
LATER THAN FIVE DAYS AFTER THE ORAL OR WRITTEN REQUEST IS
SUBMITTED. FOR AN EXPEDITED REVIEW, THE PLAN MEMBER'S PROVIDER 2,869
MUST CERTIFY THAT THE REQUESTED OR RECOMMENDED THERAPY WOULD BE 2,870
SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED. 2,871
(C) THE EXTERNAL REVIEW PROCESS ESTABLISHED BY A PLAN 2,874
SHALL MEET ALL OF THE FOLLOWING CRITERIA:
(1) EXCEPT AS PROVIDED IN DIVISION (E) OF THIS SECTION, 2,876
THE PROCESS SHALL AFFORD ALL PLAN MEMBERS WHO MEET THE CRITERIA 2,877
SET FORTH IN DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE 2,878
THE PLAN'S DECISION TO DENY COVERAGE OF THE RECOMMENDED OR 2,879
64
REQUESTED THERAPY REVIEWED UNDER THE PROCESS. EACH ELIGIBLE PLAN 2,881
MEMBER SHALL BE NOTIFIED OF THAT OPPORTUNITY WITHIN THIRTY 2,882
BUSINESS DAYS AFTER THE PLAN DENIES COVERAGE. 2,883
(2) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 2,885
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 2,886
SECTION 3901.80 OF THE REVISED CODE. THE INDEPENDENT REVIEW 2,888
ORGANIZATION SHALL SELECT A PANEL TO CONDUCT THE REVIEW, WHICH 2,889
PANEL SHALL BE COMPOSED OF AT LEAST THREE PHYSICIANS OR OTHER 2,890
PROVIDERS WHO, THROUGH CLINICAL EXPERIENCE IN THE PAST THREE 2,891
YEARS, ARE EXPERTS IN THE TREATMENT OF THE PLAN MEMBER'S MEDICAL 2,892
CONDITION AND KNOWLEDGEABLE ABOUT THE RECOMMENDED OR REQUESTED 2,893
THERAPY. IF THE INDEPENDENT REVIEW ORGANIZATION RETAINED BY THE 2,894
PLAN IS AN ACADEMIC MEDICAL CENTER, THE PANEL MAY INCLUDE EXPERTS 2,895
AFFILIATED WITH OR EMPLOYED BY THE ACADEMIC MEDICAL CENTER. 2,896
IN EITHER OF THE FOLLOWING CIRCUMSTANCES, AN EXCEPTION MAY 2,898
BE MADE TO THE REQUIREMENT THAT THE REVIEW BE CONDUCTED BY AN 2,899
EXPERT PANEL COMPOSED OF A MINIMUM OF THREE PHYSICIANS OR OTHER 2,900
PROVIDERS:
(a) A REVIEW MAY BE CONDUCTED BY AN EXPERT PANEL COMPOSED 2,902
OF ONLY TWO PHYSICIANS OR OTHER PROVIDERS IF A PLAN MEMBER HAS 2,903
CONSENTED IN WRITING TO A REVIEW BY THE SMALLER PANEL. 2,904
(b) A REVIEW MAY BE CONDUCTED BY A SINGLE EXPERT PHYSICIAN 2,906
OR OTHER PROVIDER IF ONLY THE EXPERT PHYSICIAN OR OTHER PROVIDER 2,907
IS AVAILABLE FOR THE REVIEW. 2,908
(3) NEITHER THE PLAN NOR THE PLAN MEMBER SHALL CHOOSE, OR 2,910
CONTROL THE CHOICE OF, THE PHYSICIAN OR OTHER PROVIDER EXPERTS. 2,911
(4) THE SELECTED EXPERTS, ANY HEALTH CARE FACILITY WITH 2,913
WHICH AN EXPERT IS AFFILIATED, AND THE INDEPENDENT REVIEW 2,914
ORGANIZATION ARRANGING FOR THE EXPERTS' REVIEW SHALL NOT HAVE ANY 2,915
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 2,916
FOLLOWING:
(a) THE PLAN OR ANY OFFICER, DIRECTOR, OR MANAGERIAL 2,918
EMPLOYEE OF THE PLAN; 2,919
(b) THE PLAN MEMBER, THE PLAN MEMBER'S PHYSICIAN, OR THE 2,921
65
PRACTICE GROUP OF THE PLAN MEMBER'S PHYSICIAN; 2,922
(c) THE HEALTH CARE FACILITY AT WHICH THE RECOMMENDED OR 2,924
REQUESTED THERAPY WOULD BE PROVIDED; 2,925
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 2,927
DEVICE, PROCEDURE, OR THERAPY INVOLVED IN THE RECOMMENDED OR 2,928
REQUESTED THERAPY. HOWEVER, EXPERTS AFFILIATED WITH ACADEMIC 2,930
MEDICAL CENTERS WHO PROVIDE HEALTH CARE SERVICES TO MEMBERS OF 2,931
THE PLAN MAY SERVE AS EXPERTS ON THE REVIEW PANEL. FURTHER, 2,932
EXPERTS WITH STAFF PRIVILEGES AT A HEALTH CARE FACILITY THAT 2,933
PROVIDES HEALTH CARE SERVICES TO MEMBERS OF THE PLAN, AS WELL AS 2,934
EXPERTS WHO HAVE A CONTRACTUAL RELATIONSHIP WITH THE PLAN, BUT 2,935
WHO WERE NOT INVOLVED WITH THE PLAN'S DENIAL OF COVERAGE FOR THE 2,937
THERAPY UNDER REVIEW, MAY SERVE AS EXPERTS ON THE REVIEW PANEL. 2,938
THESE NONAFFILIATION PROVISIONS DO NOT PRECLUDE A PLAN FROM 2,939
PAYING FOR THE EXPERTS' REVIEW, AS SPECIFIED IN DIVISION (C)(5) 2,940
OF THIS SECTION.
(5) PLAN MEMBERS SHALL NOT BE REQUIRED TO PAY FOR ANY PART 2,942
OF THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE 2,943
BY THE PLAN. 2,944
(6) THE PLAN SHALL PROVIDE TO THE INDEPENDENT REVIEW 2,946
ORGANIZATION ARRANGING FOR THE EXPERTS' REVIEW A COPY OF THOSE 2,947
RECORDS IN THE PLAN'S POSSESSION THAT ARE RELEVANT TO THE PLAN 2,948
MEMBER'S MEDICAL CONDITION AND THE REVIEW. THE RECORDS SHALL BE 2,949
DISCLOSED SOLELY TO THE EXPERT REVIEWERS AND SHALL BE USED SOLELY 2,950
FOR THE PURPOSE OF THIS SECTION. AT THE REQUEST OF THE EXPERT 2,951
REVIEWERS, THE PLAN OR THE PHYSICIAN REQUESTING THE THERAPY SHALL 2,952
PROVIDE ANY ADDITIONAL INFORMATION THAT THE EXPERT REVIEWERS 2,953
REQUEST TO COMPLETE THE REVIEW. AN EXPERT REVIEWER IS NOT 2,954
REQUIRED TO RENDER AN OPINION IF THE REVIEWER HAS NOT RECEIVED 2,955
ANY REQUESTED INFORMATION THAT THE REVIEWER CONSIDERS NECESSARY 2,956
TO COMPLETE THE REVIEW.
(7)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 2,958
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 2,959
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 2,961
66
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 2,964
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 2,965
COPY OF ITS DECISION TO THE PLAN AND THE PLAN MEMBER. IF THE
PLAN MEMBER'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING 2,967
HEALTH CARE SERVICES TO THE PLAN MEMBER REQUESTED THE REVIEW, THE 2,968
INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A COPY OF ITS 2,971
DECISION TO THE PLAN MEMBER'S PROVIDER OR THE HEALTH CARE
FACILITY. 2,972
(b) IN CONDUCTING THE REVIEW, THE EXPERTS ON THE PANEL 2,974
SHALL TAKE INTO ACCOUNT ALL OF THE FOLLOWING: 2,975
(i) INFORMATION SUBMITTED BY THE PLAN, THE PLAN MEMBER, 2,978
AND THE PLAN MEMBER'S PHYSICIAN, INCLUDING THE PLAN MEMBER'S
MEDICAL RECORDS AND THE STANDARDS, CRITERIA, AND CLINICAL 2,980
RATIONALE USED BY THE PLAN TO REACH ITS COVERAGE DECISION; 2,981
(ii) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 2,983
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 2,984
ORGANIZATIONS;
(iii) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 2,986
SCIENTIFIC LITERATURE AND PUBLISHED OPINIONS OF NATIONALLY 2,987
RECOGNIZED MEDICAL EXPERTS; 2,988
(iv) CLINICAL GUIDELINES ADOPTED BY RELEVANT NATIONAL 2,990
MEDICAL SOCIETIES; 2,991
(v) SAFETY, EFFICACY, APPROPRIATENESS, AND COST 2,993
EFFECTIVENESS.
(8) EACH EXPERT ON THE PANEL SHALL PROVIDE THE INDEPENDENT 2,995
REVIEW ORGANIZATION WITH A PROFESSIONAL OPINION AS TO WHETHER 2,996
THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE RECOMMENDED 2,997
OR REQUESTED THERAPY IS LIKELY TO BE MORE BENEFICIAL TO THE PLAN 2,998
MEMBER THAN STANDARD THERAPIES. 2,999
(9) EACH EXPERT'S OPINION SHALL BE PRESENTED IN WRITTEN 3,001
FORM AND SHALL INCLUDE THE FOLLOWING INFORMATION: 3,002
(a) A DESCRIPTION OF THE PLAN MEMBER'S CONDITION; 3,004
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO 3,006
67
DETERMINING WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE 3,007
THAT THE RECOMMENDED OR REQUESTED THERAPY IS MORE LIKELY THAN NOT 3,008
TO BE MORE BENEFICIAL TO THE PLAN MEMBER THAN STANDARD THERAPIES; 3,009
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS 3,011
PUBLISHED IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR 3,013
THE PUBLISHED OPINIONS OF MEDICAL EXPERTS OR SPECIALTY SOCIETIES; 3,015
(d) A DESCRIPTION OF THE PLAN MEMBER'S SUITABILITY TO 3,017
RECEIVE THE RECOMMENDED OR REQUESTED THERAPY ACCORDING TO A 3,018
TREATMENT PROTOCOL IN A CLINICAL TRIAL, IF APPLICABLE. 3,020
(10) THE INDEPENDENT REVIEW ORGANIZATION SHALL PROVIDE THE 3,022
PLAN WITH THE OPINIONS OF THE EXPERTS. THE PLAN SHALL MAKE THE 3,023
EXPERTS' OPINIONS AVAILABLE TO THE PLAN MEMBER AND THE PLAN 3,024
MEMBER'S PHYSICIAN, UPON REQUEST. 3,026
(11) THE OPINION OF THE MAJORITY OF THE EXPERTS ON THE 3,028
PANEL, RENDERED PURSUANT TO DIVISION (C)(8) OF THIS SECTION, IS 3,029
BINDING ON THE PLAN WITH RESPECT TO THAT PLAN MEMBER. IF THE 3,030
OPINIONS OF THE EXPERTS ON THE PANEL ARE EVENLY DIVIDED AS TO 3,032
WHETHER THE THERAPY SHOULD BE COVERED, THE PLAN'S FINAL DECISION 3,033
SHALL BE IN FAVOR OF COVERAGE. IF LESS THAN A MAJORITY OF THE 3,034
EXPERTS ON THE PANEL RECOMMEND COVERAGE OF THE THERAPY, THE PLAN 3,035
MAY, IN ITS DISCRETION, COVER THE THERAPY. HOWEVER, ANY COVERAGE 3,036
PROVIDED PURSUANT TO DIVISION (C)(11) OF THIS SECTION IS SUBJECT 3,037
TO THE TERMS, LIMITATIONS, AND CONDITIONS OF THE PLAN. 3,038
(12) THE PLAN SHALL HAVE WRITTEN POLICIES DESCRIBING THE 3,040
EXTERNAL REVIEW PROCESS. 3,041
(D) IF A PLAN'S INITIAL DENIAL OF COVERAGE FOR A THERAPY 3,043
RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF THIS 3,044
SECTION IS BASED UPON AN EXTERNAL REVIEW OF THAT THERAPY MEETING 3,045
THE REQUIREMENTS OF DIVISION (C) OF THIS SECTION, THIS SECTION 3,047
SHALL NOT BE A BASIS FOR REQUIRING A SECOND EXTERNAL REVIEW OF 3,048
THE RECOMMENDED OR REQUESTED THERAPY. 3,049
(E) AT ANY TIME DURING THE EXTERNAL REVIEW PROCESS, THE 3,052
PLAN MAY ELECT TO COVER THE RECOMMENDED OR REQUESTED HEALTH CARE
SERVICE AND TERMINATE THE REVIEW. THE PLAN SHALL NOTIFY THE PLAN 3,054
68
MEMBER AND ALL OTHER PARTIES INVOLVED BY MAIL OR, WITH CONSENT OR 3,055
APPROVAL OF THE PLAN MEMBER, BY ELECTRONIC MEANS. 3,056
(F) THE PLAN SHALL ANNUALLY FILE A CERTIFICATE WITH THE 3,058
SUPERINTENDENT OF INSURANCE CERTIFYING ITS COMPLIANCE WITH THE 3,059
REQUIREMENTS OF THIS SECTION. 3,060
Sec. 3923.78. NOTHING IN SECTIONS 3923.75 TO 3923.79 OF 3,062
THE REVISED CODE SHALL BE CONSTRUED TO CREATE A CAUSE OF ACTION 3,064
AGAINST ANY OF THE FOLLOWING:
(A) AN EMPLOYER THAT PROVIDES HEALTH CARE BENEFITS TO 3,068
EMPLOYEES THROUGH AN INSURER;
(B) A CLINICAL PEER OR INDEPENDENT REVIEW ORGANIZATION 3,071
THAT PARTICIPATES IN AN EXTERNAL REVIEW UNDER SECTION 3923.76 OR 3,072
3923.77 OF THE REVISED CODE; 3,073
(C) A PLAN THAT PROVIDES COVERAGE FOR BENEFITS PURSUANT TO 3,077
SECTION 3923.76 OR 3923.77 OF THE REVISED CODE. 3,078
Sec. 3923.79. CONSISTENT WITH THE RULES OF EVIDENCE, A 3,081
WRITTEN DECISION OR OPINION PREPARED BY AN INDEPENDENT REVIEW 3,082
ORGANIZATION UNDER SECTION 3923.76 OR 3923.77 OF THE REVISED CODE 3,083
SHALL BE ADMISSIBLE IN ANY CIVIL ACTION RELATED TO THE COVERAGE 3,084
DECISION THAT WAS THE SUBJECT OF THE DECISION OR OPINION. THE 3,085
INDEPENDENT REVIEW ORGANIZATION'S DECISION OR OPINION SHALL BE 3,086
PRESUMED TO BE A SCIENTIFICALLY VALID AND ACCURATE DESCRIPTION OF 3,087
THE STATE OF MEDICAL KNOWLEDGE AT THE TIME IT WAS WRITTEN. 3,088
CONSISTENT WITH THE RULES OF EVIDENCE, ANY PARTY TO A CIVIL 3,091
ACTION RELATED TO A PLAN'S DECISION INVOLVING AN INVESTIGATIONAL
OR EXPERIMENTAL DRUG, DEVICE, OR TREATMENT MAY INTRODUCE INTO 3,092
EVIDENCE ANY APPLICABLE MEDICARE REIMBURSEMENT STANDARDS 3,093
ESTABLISHED UNDER TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 3,095
STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED. 3,096
Sec. 5747.01. Except as otherwise expressly provided or 3,105
clearly appearing from the context, any term used in this chapter 3,106
has the same meaning as when used in a comparable context in the 3,107
Internal Revenue Code, and all other statutes of the United 3,108
States relating to federal income taxes. 3,109
69
As used in this chapter: 3,111
(A) "Adjusted gross income" or "Ohio adjusted gross 3,113
income" means adjusted gross income as defined and used in the 3,114
Internal Revenue Code, adjusted as provided in divisions (A)(1) 3,116
to (17) of this section:
(1) Add interest or dividends on obligations or securities 3,118
of any state or of any political subdivision or authority of any 3,119
state, other than this state and its subdivisions and 3,120
authorities.
(2) Add interest or dividends on obligations of any 3,122
authority, commission, instrumentality, territory, or possession 3,123
of the United States that are exempt from federal income taxes 3,124
but not from state income taxes. 3,125
(3) Deduct interest or dividends on obligations of the 3,127
United States and its territories and possessions or of any 3,128
authority, commission, or instrumentality of the United States to 3,129
the extent included in federal adjusted gross income but exempt 3,130
from state income taxes under the laws of the United States. 3,131
(4) Deduct disability and survivor's benefits to the 3,133
extent included in federal adjusted gross income. 3,134
(5) Deduct benefits under Title II of the Social Security 3,136
Act and tier 1 railroad retirement benefits to the extent 3,137
included in federal adjusted gross income under section 86 of the 3,138
Internal Revenue Code. 3,139
(6) Add, in the case of a taxpayer who is a beneficiary of 3,141
a trust that makes an accumulation distribution as defined in 3,142
section 665 of the Internal Revenue Code, the portion, if any, of 3,143
such distribution that does not exceed the undistributed net 3,144
income of the trust for the three taxable years preceding the 3,145
taxable year in which the distribution is made. "Undistributed 3,146
net income of a trust" means the taxable income of the trust 3,147
increased by (a)(i) the additions to adjusted gross income 3,148
required under division (A) of this section and (ii) the personal 3,149
exemptions allowed to the trust pursuant to section 642(b) of the 3,150
70
Internal Revenue Code, and decreased by (b)(i) the deductions to 3,151
adjusted gross income required under division (A) of this 3,152
section, (ii) the amount of federal income taxes attributable to 3,153
such income, and (iii) the amount of taxable income that has been 3,154
included in the adjusted gross income of a beneficiary by reason 3,155
of a prior accumulation distribution. Any undistributed net 3,156
income included in the adjusted gross income of a beneficiary 3,157
shall reduce the undistributed net income of the trust commencing 3,158
with the earliest years of the accumulation period. 3,159
(7) Deduct the amount of wages and salaries, if any, not 3,161
otherwise allowable as a deduction but that would have been 3,162
allowable as a deduction in computing federal adjusted gross 3,163
income for the taxable year, had the targeted jobs credit allowed 3,164
and determined under sections 38, 51, and 52 of the Internal 3,165
Revenue Code not been in effect. 3,166
(8) Deduct any interest or interest equivalent on public 3,168
obligations and purchase obligations to the extent included in 3,169
federal adjusted gross income. 3,170
(9) Add any loss or deduct any gain resulting from the 3,172
sale, exchange, or other disposition of public obligations to the 3,173
extent included in federal adjusted gross income. 3,174
(10) Regarding tuition credits purchased under Chapter 3,176
3334. of the Revised Code: 3,177
(a) Deduct the following: 3,179
(i) For credits that as of the end of the taxable year 3,182
have not been refunded pursuant to the termination of a tuition
payment contract under section 3334.10 of the Revised Code, the 3,184
amount of income related to the credits, to the extent included 3,185
in federal adjusted gross income;
(ii) For credits that during the taxable year have been 3,188
refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the excess of 3,189
the total purchase price of the tuition credits refunded over the 3,190
amount of refund, to the extent the amount of the excess was not 3,191
71
deducted in determining federal adjusted gross income;. 3,192
(b) Add the following: 3,194
(i) For credits that as of the end of the taxable year 3,197
have not been refunded pursuant to the termination of a tuition
payment contract under section 3334.10 of the Revised Code, the 3,198
amount of loss related to the credits, to the extent the amount 3,199
of the loss was deducted in determining federal adjusted gross 3,200
income;
(ii) For credits that during the taxable year have been 3,203
refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the excess of 3,205
the amount of refund over the purchase price of each tuition 3,206
credit refunded, to the extent not included in federal adjusted 3,207
gross income.
(11)(a) Deduct, in the case of a self-employed individual 3,209
as defined in section 401(c)(1) of the Internal Revenue Code and 3,210
to the extent not otherwise allowable as a deduction OR EXCLUSION 3,211
in computing federal OR OHIO adjusted gross income for the 3,213
taxable year, the amount THE TAXPAYER paid during the taxable 3,215
year for insurance that constitutes medical care INSURANCE AND 3,216
QUALIFIED LONG-TERM CARE INSURANCE for the taxpayer, the 3,217
taxpayer's spouse, and dependents. No deduction FOR MEDICAL CARE 3,219
INSURANCE under division (A)(11) of this section shall be allowed 3,220
EITHER to any taxpayer who is eligible to participate in any 3,221
subsidized health plan maintained by any employer of the taxpayer 3,222
or of the TAXPAYER'S spouse of the taxpayer. No deduction under 3,224
division (A)(11) of this section shall be allowed to the extent 3,226
that the sum of such deduction and any related deduction 3,227
allowable in computing federal adjusted gross income for the 3,228
taxable year exceeds the taxpayer's earned income, within the 3,229
meaning of section 401(c) of the Internal Revenue Code, derived 3,230
by the taxpayer from the trade or business with respect to which 3,231
the plan providing the medical coverage is established., OR TO 3,234
ANY TAXPAYER WHO IS ENTITLED TO, OR ON APPLICATION WOULD BE
72
ENTITLED TO, BENEFITS UNDER PART A OF TITLE XVIII OF THE "SOCIAL 3,236
SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C. 301, AS AMENDED. 3,237
FOR THE PURPOSES OF DIVISION (A)(11)(a) OF THIS SECTION, 3,238
"SUBSIDIZED HEALTH PLAN" MEANS A HEALTH PLAN FOR WHICH THE 3,240
EMPLOYER PAYS ANY PORTION OF THE PLAN'S COST. THE DEDUCTION 3,241
ALLOWED UNDER DIVISION (A)(11)(a) OF THIS SECTION SHALL BE THE 3,244
NET OF ANY RELATED PREMIUM REFUNDS, RELATED PREMIUM
REIMBURSEMENTS, OR RELATED INSURANCE PREMIUM DIVIDENDS RECEIVED 3,247
DURING THE TAXABLE YEAR. 3,248
(b) DEDUCT, TO THE EXTENT NOT OTHERWISE DEDUCTED OR 3,250
EXCLUDED IN COMPUTING FEDERAL OR OHIO ADJUSTED GROSS INCOME 3,251
DURING THE TAXABLE YEAR, THE AMOUNT THE TAXPAYER PAID DURING THE 3,252
TAXABLE YEAR, NOT COMPENSATED FOR BY ANY INSURANCE OR OTHERWISE, 3,253
FOR MEDICAL CARE OF THE TAXPAYER, THE TAXPAYER'S SPOUSE, AND 3,254
DEPENDENTS, TO THE EXTENT THE EXPENSES EXCEED SEVEN AND ONE-HALF 3,255
PER CENT OF THE TAXPAYER'S FEDERAL ADJUSTED GROSS INCOME. 3,256
(c) FOR PURPOSES OF DIVISION (A)(11) OF THIS SECTION, 3,258
"MEDICAL CARE" HAS THE MEANING GIVEN IN SECTION 213 OF THE 3,260
INTERNAL REVENUE CODE, SUBJECT TO THE SPECIAL RULES, LIMITATIONS, 3,261
AND EXCLUSIONS SET FORTH THEREIN, AND "QUALIFIED LONG-TERM CARE" 3,262
HAS THE SAME MEANING GIVEN IN SECTION 7702(B)(b) OF THE INTERNAL 3,263
REVENUE CODE. 3,264
(12)(a) Deduct any amount included in federal adjusted 3,266
gross income solely because the amount represents a reimbursement 3,267
or refund of expenses that in a previous ANY year the taxpayer 3,268
had deducted as an itemized deduction pursuant to section 63 of 3,269
the Internal Revenue Code and applicable United States department 3,271
of the treasury regulations. THE DEDUCTION OTHERWISE ALLOWED 3,272
UNDER DIVISION (A)(12)(a) OF THIS SECTION SHALL BE REDUCED TO THE 3,274
EXTENT THE REIMBURSEMENT IS ATTRIBUTABLE TO AN AMOUNT THE 3,275
TAXPAYER DEDUCTED UNDER THIS SECTION IN ANY TAXABLE YEAR. 3,276
(b) ADD ANY AMOUNT NOT OTHERWISE INCLUDED IN OHIO ADJUSTED 3,278
GROSS INCOME FOR ANY TAXABLE YEAR TO THE EXTENT THAT THE AMOUNT 3,281
IS ATTRIBUTABLE TO THE RECOVERY DURING THE TAXABLE YEAR OF ANY 3,283
73
AMOUNT DEDUCTED OR EXCLUDED IN COMPUTING FEDERAL OR OHIO ADJUSTED 3,284
GROSS INCOME IN ANY TAXABLE YEAR.
(13) Deduct any portion of the deduction described in 3,286
section 1341(a)(2) of the Internal Revenue Code, for repaying 3,287
previously reported income received under a claim of right, that 3,288
meets both of the following requirements: 3,289
(a) It is allowable for repayment of an item that was 3,291
included in the taxpayer's adjusted gross income for a prior 3,292
taxable year and did not qualify for a credit under division (A) 3,293
or (B) of section 5747.05 of the Revised Code for that year; 3,294
(b) It does not otherwise reduce the taxpayer's adjusted 3,296
gross income for the current or any other taxable year. 3,297
(14) Deduct an amount equal to the deposits made to, and 3,299
net investment earnings of, a medical savings account during the 3,300
taxable year, in accordance with section 3924.66 of the Revised 3,301
Code. The deduction allowed by division (A)(14) of this section 3,302
does not apply to medical savings account deposits and earnings 3,303
otherwise deducted or excluded for the current or any other 3,304
taxable year from the taxpayer's federal adjusted gross income. 3,305
(15)(a) Add an amount equal to the funds withdrawn from a 3,307
medical savings account during the taxable year, and the net 3,308
investment earnings on those funds, when the funds withdrawn were 3,309
used for any purpose other than to reimburse an account holder 3,310
for, or to pay, eligible medical expenses, in accordance with 3,311
section 3924.66 of the Revised Code;
(b) Add the amounts distributed from a medical savings 3,313
account under division (A)(2) of section 3924.68 of the Revised 3,314
Code during the taxable year. 3,315
(16) Add any amount claimed as a credit under section 3,317
5747.059 of the Revised Code to the extent that such amount 3,318
satisfies either of the following:
(a) The amount was deducted or excluded from the 3,320
computation of the taxpayer's federal adjusted gross income as 3,321
required to be reported for the taxpayer's taxable year under the 3,322
74
Internal Revenue Code;
(b) The amount resulted in a reduction of the taxpayer's 3,324
federal adjusted gross income as required to be reported for any 3,325
of the taxpayer's taxable years under the Internal Revenue Code. 3,326
(17) Deduct the amount contributed by the taxpayer to an 3,328
individual development account program established by a county 3,329
department of human services pursuant to sections 329.11 to 3,330
329.14 of the Revised Code for the purpose of matching funds 3,331
deposited by program participants. On request of the tax 3,332
commissioner, the taxpayer shall provide any information that, in
the tax commissioner's opinion, is necessary to establish the 3,333
amount deducted under division (A)(17) of this section. 3,334
(B) "Business income" means income arising from 3,336
transactions, activities, and sources in the regular course of a 3,337
trade or business and includes income from tangible and 3,338
intangible property if the acquisition, rental, management, and 3,339
disposition of the property constitute integral parts of the 3,340
regular course of a trade or business operation. 3,341
(C) "Nonbusiness income" means all income other than 3,343
business income and may include, but is not limited to, 3,344
compensation, rents and royalties from real or tangible personal 3,345
property, capital gains, interest, dividends and distributions, 3,346
patent or copyright royalties, or lottery winnings, prizes, and 3,347
awards. 3,348
(D) "Compensation" means any form of remuneration paid to 3,350
an employee for personal services. 3,351
(E) "Fiduciary" means a guardian, trustee, executor, 3,353
administrator, receiver, conservator, or any other person acting 3,354
in any fiduciary capacity for any individual, trust, or estate. 3,355
(F) "Fiscal year" means an accounting period of twelve 3,357
months ending on the last day of any month other than December. 3,358
(G) "Individual" means any natural person. 3,360
(H) "Internal Revenue Code" means the "Internal Revenue 3,362
Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 3,363
75
(I) "Resident" means: 3,365
(1) An individual who is domiciled in this state, subject 3,367
to section 5747.24 of the Revised Code; 3,368
(2) The estate of a decedent who at the time of death was 3,371
domiciled in this state. The domicile tests of section 5747.24 3,372
of the Revised Code and any election under section 5747.25 of the 3,373
Revised Code are not controlling for purposes of division (I)(2) 3,374
of this section.
(J) "Nonresident" means an individual or estate that is 3,376
not a resident. An individual who is a resident for only part of 3,377
a taxable year is a nonresident for the remainder of that taxable 3,378
year. 3,379
(K) "Pass-through entity" has the same meaning as in 3,381
section 5733.04 of the Revised Code. 3,382
(L) "Return" means the notifications and reports required 3,384
to be filed pursuant to this chapter for the purpose of reporting 3,385
the tax due and includes declarations of estimated tax when so 3,386
required. 3,387
(M) "Taxable year" means the calendar year or the 3,389
taxpayer's fiscal year ending during the calendar year, or 3,390
fractional part thereof, upon which the adjusted gross income is 3,391
calculated pursuant to this chapter. 3,392
(N) "Taxpayer" means any person subject to the tax imposed 3,394
by section 5747.02 of the Revised Code or any pass-through entity 3,395
that makes the election under division (D) of section 5747.08 of 3,396
the Revised Code.
(O) "Dependents" means dependents as defined in the 3,398
Internal Revenue Code and as claimed in the taxpayer's federal 3,399
income tax return for the taxable year or which the taxpayer 3,400
would have been permitted to claim had the taxpayer filed a 3,401
federal income tax return. 3,403
(P) "Principal county of employment" means, in the case of 3,405
a nonresident, the county within the state in which a taxpayer 3,406
performs services for an employer or, if those services are 3,407
76
performed in more than one county, the county in which the major 3,408
portion of the services are performed. 3,409
(Q) As used in sections 5747.50 to 5747.55 of the Revised 3,411
Code:
(1) "Subdivision" means any county, municipal corporation, 3,413
park district, or township. 3,414
(2) "Essential local government purposes" includes all 3,416
functions that any subdivision is required by general law to 3,417
exercise, including like functions that are exercised under a 3,418
charter adopted pursuant to the Ohio Constitution. 3,419
(R) "Overpayment" means any amount already paid that 3,421
exceeds the figure determined to be the correct amount of the 3,422
tax. 3,423
(S) "Taxable income" applies to estates only and means 3,425
taxable income as defined and used in the Internal Revenue Code 3,426
adjusted as follows: 3,427
(1) Add interest or dividends on obligations or securities 3,429
of any state or of any political subdivision or authority of any 3,430
state, other than this state and its subdivisions and 3,431
authorities; 3,432
(2) Add interest or dividends on obligations of any 3,434
authority, commission, instrumentality, territory, or possession 3,435
of the United States that are exempt from federal income taxes 3,436
but not from state income taxes; 3,437
(3) Add the amount of personal exemption allowed to the 3,439
estate pursuant to section 642(b) of the Internal Revenue Code; 3,440
(4) Deduct interest or dividends on obligations of the 3,442
United States and its territories and possessions or of any 3,443
authority, commission, or instrumentality of the United States 3,444
that are exempt from state taxes under the laws of the United 3,445
States; 3,446
(5) Deduct the amount of wages and salaries, if any, not 3,448
otherwise allowable as a deduction but that would have been 3,449
allowable as a deduction in computing federal taxable income for 3,450
77
the taxable year, had the targeted jobs credit allowed under 3,451
sections 38, 51, and 52 of the Internal Revenue Code not been in 3,452
effect; 3,453
(6) Deduct any interest or interest equivalent on public 3,455
obligations and purchase obligations to the extent included in 3,456
federal taxable income; 3,457
(7) Add any loss or deduct any gain resulting from sale, 3,459
exchange, or other disposition of public obligations to the 3,460
extent included in federal taxable income; 3,461
(8) Except in the case of the final return of an estate, 3,463
add any amount deducted by the taxpayer on both its Ohio estate 3,464
tax return pursuant to section 5731.14 of the Revised Code, and 3,465
on its federal income tax return in determining either federal 3,466
adjusted gross income or federal taxable income; 3,467
(9)(a) Deduct any amount included in federal taxable 3,469
income solely because the amount represents a reimbursement or 3,470
refund of expenses that in a previous year the decedent had 3,471
deducted as an itemized deduction pursuant to section 63 of the 3,472
Internal Revenue Code and applicable treasury regulations;. THE 3,474
DEDUCTION OTHERWISE ALLOWED UNDER DIVISION (S)(9)(a) OF THIS 3,476
SECTION SHALL BE REDUCED TO THE EXTENT THE REIMBURSEMENT IS
ATTRIBUTABLE TO AN AMOUNT THE TAXPAYER OR DECEDENT DEDUCTED UNDER 3,477
THIS SECTION IN ANY TAXABLE YEAR. 3,478
(b) ADD ANY AMOUNT NOT OTHERWISE INCLUDED IN OHIO TAXABLE 3,481
INCOME FOR ANY TAXABLE YEAR TO THE EXTENT THAT THE AMOUNT IS 3,482
ATTRIBUTABLE TO THE RECOVERY DURING THE TAXABLE YEAR OF ANY 3,483
AMOUNT DEDUCTED OR EXCLUDED IN COMPUTING FEDERAL OR OHIO TAXABLE 3,484
INCOME IN ANY TAXABLE YEAR.
(10) Deduct any portion of the deduction described in 3,486
section 1341(a)(2) of the Internal Revenue Code, for repaying 3,487
previously reported income received under a claim of right, that 3,488
meets both of the following requirements: 3,489
(a) It is allowable for repayment of an item that was 3,491
included in the taxpayer's taxable income or the decedent's 3,492
78
adjusted gross income for a prior taxable year and did not 3,493
qualify for a credit under division (A) or (B) of section 5747.05 3,494
of the Revised Code for that year. 3,495
(b) It does not otherwise reduce the taxpayer's taxable 3,497
income or the decedent's adjusted gross income for the current or 3,498
any other taxable year. 3,499
(11) Add any amount claimed as a credit under section 3,501
5747.059 of the Revised Code to the extent that the amount 3,502
satisfies either of the following: 3,503
(a) The amount was deducted or excluded from the 3,505
computation of the taxpayer's federal taxable income as required 3,506
to be reported for the taxpayer's taxable year under the Internal 3,507
Revenue Code;
(b) The amount resulted in a reduction in the taxpayer's 3,509
federal taxable income as required to be reported for any of the 3,510
taxpayer's taxable years under the Internal Revenue Code. 3,511
(T) "School district income" and "school district income 3,513
tax" have the same meanings as in section 5748.01 of the Revised 3,514
Code. 3,515
(U) As used in divisions (A)(8), (A)(9), (S)(6), and 3,517
(S)(7) of this section, "public obligations," "purchase 3,518
obligations," and "interest or interest equivalent" have the same 3,519
meanings as in section 5709.76 of the Revised Code. 3,520
(V) "Limited liability company" means any limited 3,522
liability company formed under Chapter 1705. of the Revised Code 3,523
or under the laws of any other state. 3,524
(W) "Pass-through entity investor" means any person who, 3,526
during any portion of a taxable year of a pass-through entity, is 3,527
a partner, member, shareholder, or investor in that pass-through 3,528
entity.
(X) "Banking day" has the same meaning as in section 3,530
1304.01 of the Revised Code. 3,531
(Y) "Month" means a calendar month. 3,533
(Z) "Quarter" means the first three months, the second 3,535
79
three months, the third three months, or the last three months of 3,536
the taxpayer's taxable year.
(AA) Any term used in this chapter that is not otherwise 3,538
defined in this section and that is not used in a comparable 3,539
context in the Internal Revenue Code and other statutes of the 3,540
United States relating to federal income taxes has the same 3,541
meaning as in section 5733.40 of the Revised Code. 3,542
Section 2. That existing sections 1751.11, 1751.19, 3,544
1751.33, 1751.35, 1751.77, 1751.78, 1751.81, 1751.82, 1751.83, 3,545
1751.84, 1751.85, 1753.24, and 5747.01 of the Revised Code are 3,546
hereby repealed.
Section 3. Sections 1 and 2 of this act, except for the 3,548
amendment of sections 1751.11, 1751.33, and 5747.01 and the 3,549
enactment of sections 1753.13 and 3923.65 of the Revised Code, 3,550
shall take effect on May 1, 2000. The enactment of section 3,551
1753.13 and the amendment of sections 1751.11, 1751.33, and 3,552
5747.01 of the Revised Code shall take effect on the effective
date of this section. The enactment of section 3923.65 of the 3,553
Revised Code shall take effect 180 days after the effective date 3,554
of this section.
Section 4. Section 3923.65 of the Revised Code applies 3,556
only to policies issued, issued for delivery, or renewed in this 3,558
state 180 days after the effective date of this section and 3,559
thereafter.
Section 5. The amendment by this act of section 5747.01 of 3,561
the Revised Code applies to taxable years beginning on or after 3,562
January 1, 1999.
Section 6. It is the intent of the General Assembly that 3,564
sections 1751.84, 1751.85, 3923.67, 3923.68, 3923.76, and 3923.77 3,565
of the Revised Code, as enacted or amended by this act, provide 3,566
health insuring corporation enrollees, insureds, and governmental 3,567
plan members with a means for resolving health care coverage 3,569
disputes expeditiously and avoid the need for lengthy and
expensive litigation. 3,570
80
Section 7. This act shall be known as "The Patient 3,572
Protection Act of 1999."