Section 1. That sections 1349.01, 1739.05, 1739.14, 3901.38, | 12 |
3902.11, 3902.21, 3902.22, 3902.23, and 3924.21
be amended and new | 13 |
section 3901.381 and sections 3901.382,
3901.383, 3901.384, | 14 |
3901.385, 3901.386, 3901.387, 3901.388,
3901.389, 3901.3810, | 15 |
3901.3811, 3901.3812, 3901.3813, and 3901.3814 of the
Revised | 16 |
Code
be
enacted
to read as follows: | 17 |
|
(B) If, pursuant to an action for divorce, annulment, | 31 |
dissolution of marriage, or legal separation, the court
determines | 32 |
that a party who is a resident of this state is responsible
for | 33 |
obtaining health
insurance coverage for the party's former spouse | 34 |
or children or if,
pursuant to a child support order issued in | 35 |
accordance
with sections 3119.30 to 3119.58
of the Revised Code, | 36 |
the court requires a party who is a resident of this
state to | 37 |
obtain health
insurance coverage for the children who are the | 38 |
subject of the
child support order, and the party fails to obtain | 39 |
such coverage,
no provider or collection agency shall collect or | 40 |
attempt to
collect from the former spouse, children, or person | 41 |
responsible for the children, any reimbursement of
any hospital, | 42 |
surgical, or medical expenses incurred by the
provider for | 43 |
services rendered to the former spouse or children,
which expenses | 44 |
would have been covered but for the failure of the
party to obtain | 45 |
the coverage, if the former spouse, any of the children, or a | 46 |
person responsible for the children, provides the following to the | 47 |
provider or
collection agency: | 48 |
(C) If the requirements of divisions (B)(1) and (2)
of this | 53 |
section are not met, the provider or collection agency
may collect | 54 |
the hospital, surgical, or medical expenses both
from the former | 55 |
spouse or person responsible for the children
and from the party | 56 |
who failed to obtain the coverage. If the
requirements of | 57 |
divisions (B)(1) and (2) are met, the
provider or collection | 58 |
agency may collect or attempt to collect
the expenses only from | 59 |
the party. | 60 |
A party required to obtain health insurance coverage for a | 61 |
former spouse or children who fails to obtain the coverage is | 62 |
liable to the provider for the hospital, surgical, or medical | 63 |
expenses incurred by the provider as a result of the failure to | 64 |
obtain the coverage. This section does not prohibit a former | 65 |
spouse or person responsible for the children from initiating an | 66 |
action to enforce the order requiring the party to obtain health | 67 |
insurance for the former spouse or children or to collect any | 68 |
amounts the former spouse or person responsible for the children | 69 |
pays for hospital, surgical, or medical expenses for which the | 70 |
party is responsible under the order requiring the party to
obtain | 71 |
health insurance for the former spouse or children. | 72 |
(a) No collection agency or provider of hospital,
surgical, | 76 |
or medical services may report to a consumer reporting
agency, for | 77 |
inclusion in the credit file or credit report of the
former spouse | 78 |
or person responsible for the children, any
information relative | 79 |
to the nonpayment of expenses for the
services incurred by the | 80 |
provider, if the nonpayment is the
result of the failure of the | 81 |
party responsible for obtaining
health insurance coverage to | 82 |
obtain health insurance coverage. | 83 |
(a) A provider of hospital, surgical, or medical services, | 91 |
or a collection
agency, may report to a consumer reporting agency, | 92 |
for inclusion in the credit
file or credit report of the former | 93 |
spouse or person responsible for the
children, any information | 94 |
relative to the nonpayment of expenses for the
services incurred | 95 |
by the provider, if the nonpayment is the result of the
failure of | 96 |
the party responsible for obtaining health insurance coverage to | 97 |
obtain such coverage. | 98 |
(3)(a) A provider of hospital, surgical, or medical | 106 |
services, or a collection
agency, may report to a consumer | 107 |
reporting agency, for inclusion in the credit
file or credit | 108 |
report of that party, any information relative to the
nonpayment | 109 |
of expenses for the services incurred by the provider, if the | 110 |
nonpayment is the result of the failure of the party responsible | 111 |
for obtaining
health insurance coverage to obtain such coverage. | 112 |
(4) If any information described in division (D)(2) of this | 119 |
section is placed
in the credit file or credit report of the | 120 |
former spouse or person responsible
for the children, the consumer | 121 |
reporting agency shall remove the information
from the credit file | 122 |
and credit report if the former spouse or person
responsible for | 123 |
the children provides the agency with the information required
in | 124 |
divisions (B)(1) and (2) of this section. If the agency fails to | 125 |
remove
the information from the credit file or credit report | 126 |
pursuant to the terms of
the "Fair Credit Reporting Act," 84 Stat. | 127 |
1128, 15 U.S.C. 1681a, within a
reasonable time after receiving | 128 |
the information required by divisions (B)(1)
and (2) of this | 129 |
section, the former spouse may initiate an action to require
the | 130 |
agency to remove the information. | 131 |
If any information described in division (D)(3) of this | 132 |
section is placed in
the party's credit file or credit report, the | 133 |
party has the burden of proving
that the party is not responsible | 134 |
for obtaining the health insurance coverage
or, if responsible, | 135 |
that the expenses incurred are not covered expenses. If
the party | 136 |
meets that burden, the agency shall remove the information from | 137 |
the
party's credit file and credit report immediately. If the | 138 |
agency fails to
remove the information from the credit file or | 139 |
credit report immediately after
the party meets the burden, the | 140 |
party may initiate an action to require the
agency to remove the | 141 |
information. | 142 |
(B) A multiple employer welfare arrangement that is
created | 154 |
pursuant to sections 1739.01 to 1739.22 of the Revised
Code and | 155 |
that operates a group self-insurance program shall
comply with all | 156 |
laws applicable to self-funded programs in this
state, including | 157 |
sections 3901.04, 3901.041, 3901.19 to 3901.26,
3901.38, 3901.381 | 158 |
to
3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to
3902.14, | 159 |
3923.30,
3923.301, 3923.38,
3923.581, 3923.63, 3924.031,
3924.032, | 160 |
and
3924.27
of the Revised Code. | 161 |
(D) A multiple employer welfare arrangement created
pursuant | 167 |
to sections 1739.01 to 1739.22 of the Revised Code shall
provide | 168 |
benefits only to individuals who are members, employees
of | 169 |
members, or the dependents of members or employees, or are | 170 |
eligible for continuation of coverage under section 1751.53 or | 171 |
3923.38 of the Revised Code or under Title X of the "Consolidated | 172 |
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 | 173 |
U.S.C.A. 1161, as amended. | 174 |
Sec. 1739.14. (A) Each member shall pay to the multiple | 175 |
employer welfare arrangement operating a group self-insurance | 176 |
program a premium equal to its share of the arrangement's | 177 |
projected obligation for employee welfare benefit liability, | 178 |
administrative expenses, and other costs incurred by the | 179 |
arrangement as determined by the board of the arrangement or by a | 180 |
third-party administrator and approved by the board of the | 181 |
arrangement. This amount may be adjusted by the board according | 182 |
to the claims experience of each participating member in | 183 |
accordance with criteria set forth in the articles or bylaws of | 184 |
the arrangement. | 185 |
(B)(1) Except as provided in division (B)(2) of this
section | 248 |
and in section 3901.381 of the Revised Code,
within twenty-four | 249 |
days of the receipt of a completed
claim from a provider or a | 250 |
beneficiary for reimbursement for
health care services rendered by | 251 |
the provider to a beneficiary, a
third-party payer shall, in | 252 |
accordance with division (D) of this
section, make payment of any | 253 |
amount due on such claim. | 254 |
(3) Any provider or beneficiary aggrieved with respect to | 262 |
any act of a third-party payer that such provider or beneficiary | 263 |
believes to be a violation of division (B)(1) or (2) of this | 264 |
section may file a written complaint with the superintendent of | 265 |
insurance. If a series of such complaints is received by the | 266 |
superintendent with respect to a particular third-party payer and | 267 |
if, after investigation, the superintendent finds that such | 268 |
third-party payer has engaged in a series of such violations | 269 |
which, taken together, constitute a consistent pattern or a | 270 |
practice of such third-party payer to violate division (B)(1) or | 271 |
(2) of this section, the superintendent shall issue an order | 272 |
requiring such third-party payer to cease and desist from
engaging | 273 |
in such violations and to pay a late payment penalty as
specified | 274 |
in divisions (B)(4) and (5) of this section with
respect to the | 275 |
claims the superintendent finds were not timely
paid. In the | 276 |
order, the superintendent shall specify the reasons
for the | 277 |
superintendent's finding and order and state that a
hearing | 278 |
conducted
pursuant to Chapter 119. of the Revised Code shall be | 279 |
held within
fifteen days after requested in writing by the | 280 |
third-party payer.
The provisions of division (B)(3) of this | 281 |
section are in
addition to, and not in lieu of, such other | 282 |
remedies as providers
and beneficiaries may otherwise have by law. | 283 |
(5) A provider and a third-party payer may enter into a | 293 |
contractual agreement in which the timing of payments by the | 294 |
third-party payer is not directly related to the receipt of a | 295 |
completed claim. Such contractual arrangement may include | 296 |
periodic interim payment arrangements, capitation payment | 297 |
arrangements, or other payment arrangements acceptable to the | 298 |
provider and the third-party payer. Except as agreed to under | 299 |
such contract, this section does not apply to such payment | 300 |
arrangements. | 301 |
(D)(1) Notwithstanding section 1751.13 or
division (I)(2) of | 313 |
section 3923.04 of the Revised Code, a
reimbursement contract | 314 |
entered into or renewed on or after June 29,
1988, between a | 315 |
third-party payer and a hospital shall provide that reimbursement | 316 |
for any service provided by a hospital pursuant to a
reimbursement | 317 |
contract and covered under a benefits contract
shall be made | 318 |
directly to the hospital. | 319 |
(2) If the third-party payer and the hospital have not | 320 |
entered into a contract regarding the provision and reimbursement | 321 |
for covered services, the third-party payer shall accept and
honor | 322 |
a completed and validly executed assignment of benefits
with a | 323 |
hospital by a beneficiary, except when the third-party
payer has | 324 |
notified the hospital in writing of the conditions
under which the | 325 |
third-party payer will not accept and honor an
assignment of | 326 |
benefits. Such notice shall be made annually. | 327 |
(B)(1) Unless division (B)(2), (3), or (4) of this
section | 342 |
applies, when a third-party payer receives
from a
provider
or | 343 |
beneficiary a claim on the standard claim form prescribed
in
rules | 344 |
adopted by the superintendent of insurance under section
3902.22 | 345 |
of the Revised Code, the third-party payer shall pay or deny the | 346 |
claim
not
later
than
thirty days after receipt of the claim. When | 347 |
a
third-party payer denies a claim, the third-party payer shall | 348 |
notify the provider and the beneficiary. The notice shall state, | 349 |
with specificity, why the third-party payer denied the claim. | 350 |
(2) Unless division (B)(3) or (4) of this section
applies, | 351 |
when a provider or beneficiary has used the standard
claim form, | 352 |
but the third-party payer determines that reasonable
supporting | 353 |
documentation is needed to establish the third-party
payer's | 354 |
responsibility to make payment, the third-party payer
shall pay or | 355 |
deny the claim not later than forty-five days after
receipt of the | 356 |
claim.
Supporting documentation includes the verification of | 357 |
employer and beneficiary coverage under a benefits contract, | 358 |
confirmation of premium payment, medical information regarding the | 359 |
beneficiary and the services provided, information on the | 360 |
responsibility of another third-party payer to make payment, and | 361 |
information that is needed to correct material deficiencies in the | 362 |
claim related to the identification of a diagnosis, treatment, or | 363 |
provider. | 364 |
Not later than thirty days after receipt of
the claim, the | 365 |
third-party payer shall notify the provider,
beneficiary, or | 366 |
third-party payer that the supporting documentation is needed.
The | 367 |
notice shall state, with specificity, the
supporting
documentation | 368 |
needed. If any of the supporting documentation is
under the | 369 |
control of the
beneficiary, the beneficiary shall
provide the | 370 |
supporting documentation to the
third-party payer. | 371 |
The number of days that
elapse between the third-party | 372 |
payer's request for supporting
documentation and receipt of the | 373 |
requested documentation shall not
be counted for purposes of | 374 |
determining the third-party payer's
compliance with the time | 375 |
period of not more than
forty-five days for payment or denial of a | 376 |
claim. If the third-party payer requests additional
supporting | 377 |
documentation after receiving the initially requested | 378 |
documentation, the number of days that elapse between making the | 379 |
request and receiving the documentation shall be counted for | 380 |
purposes of determining the third-party payer's compliance with | 381 |
the time period of not more than forty-five days. | 382 |
When a third-party payer denies a claim, the third-party | 383 |
payer shall notify the provider and the beneficiary. The notice | 384 |
shall state, with specificity, why the third-party payer denied | 385 |
the claim. If a claim is denied because the provider failed to | 386 |
submit the supporting documentation needed to establish the | 387 |
third-party payer's responsibility to pay the claim and the | 388 |
provider in any manner charges the beneficiary an amount for the | 389 |
cost of the services, other than copayments or co-insurance | 390 |
required by a benefits contract, the provider shall notify the | 391 |
beneficiary that the charge is the result of a denied claim and | 392 |
shall notify the third-party payer that the beneficiary has been | 393 |
charged. The notices shall be made in writing and sent | 394 |
simultaneously to the beneficiary and third-party payer. In each | 395 |
notice, the provider shall include the number assigned by the | 396 |
third-party payer to the claim that was denied. | 397 |
(3) When a provider or beneficiary submits a claim by using | 405 |
the standard claim form prescribed in the superintendent's
rules, | 406 |
but the information provided in the claim is materially
deficient, | 407 |
the third-party payer shall notify the provider or
beneficiary not | 408 |
later than fifteen days after receipt of the claim.
The notice | 409 |
shall state, with specificity,
the
information needed to correct | 410 |
all material deficiencies. Once the
material deficiencies are | 411 |
corrected, the
third-party payer shall
proceed in accordance with | 412 |
division (B)(1), (2), or (4) of this section. | 413 |
It is not a violation of the notification time period of not | 414 |
more than fifteen days if a third-party payer finds after the end | 415 |
of the period that it is necessary to request information related | 416 |
to the identification of a diagnosis, treatment, or provider. | 417 |
Requests for such information shall be made as requests for | 418 |
supporting documentation under division (B)(2) of this section, | 419 |
and payment or denial of the claim is subject to the time periods | 420 |
specified in that division. | 421 |
(4) When a third-party payer is the secondary payer, the | 422 |
beneficiary shall submit to the third-party payer an explanation | 423 |
of benefits or other evidence of payment or denial by the primary | 424 |
payer not
later than thirty days after payment by the primary | 425 |
payer. The
third-party payer shall pay or deny the claim not | 426 |
later than thirty days after it
receives the explanation of | 427 |
benefits or other evidence of payment or denial
by the primary | 428 |
payer. When a third-party payer denies a claim, the third-party | 429 |
payer shall notify the provider and the beneficiary. The notice | 430 |
shall state, with specificity, why the third-party payer denied | 431 |
the claim. | 432 |
Sec. 3901.382. Beginning six months after the date specified | 450 |
in section 262 of the "Health Insurance Portability and | 451 |
Accountability Act of 1996," 110 Stat. 2027, 42 U.S.C.A. 1320d-4, | 452 |
on which a third-party payer is initially required to comply with | 453 |
a standard or implementation specification for the electronic | 454 |
exchange of health information, as adopted or established by the | 455 |
United States secretary of health and human services pursuant to | 456 |
that act, sections 3901.381, 3901.384, 3901.385, 3901.389, | 457 |
3901.3810, 3901.3811, 3901.3812, and 3901.3813 of the
Revised Code | 458 |
apply to a claim submitted to a third-party payer for payment for | 459 |
health care services
only if the claim is submitted | 460 |
electronically. A provider and third-party payer may enter into a | 461 |
contractual arrangement under which the third-party payer agrees | 462 |
to process claims that are not submitted electronically because of | 463 |
the financial hardship that electronic submission of claims would | 464 |
create for the provider or any other extenuating circumstance. | 465 |
(B) Enter into a contractual
agreement in which the timing | 472 |
of payments by the third-party
payer is not directly related to | 473 |
the receipt of a
claim form. The contractual
arrangement
may | 474 |
include periodic
interim payment arrangements,
capitation
payment | 475 |
arrangements,
or other periodic payment
arrangements
acceptable to | 476 |
the provider and the
third-party payer. Under a capitation payment | 477 |
arrangement, the third-party
payer
shall begin paying the | 478 |
capitated amounts to the
beneficiary's
primary care provider
not | 479 |
later than sixty days after the date the beneficiary
selects or is | 480 |
assigned to the provider. Under any other contractual periodic | 481 |
payment arrangement, the
contractual agreement shall state, with | 482 |
specificity, the timing
of
payments by the third-party payer. | 483 |
Sec. 3901.384. (A) Subject to division (B) of this section, | 484 |
a
third-party payer that requires timely submission of claims for | 485 |
payment for health care services shall process a claim that is | 486 |
not submitted in a timely manner if a claim for the same services | 487 |
was initially submitted to a different third-party payer or state | 488 |
or federal program that offers health care benefits and that payer | 489 |
or program has determined that it is not responsible for the cost | 490 |
of the health care services. When a claim is submitted later than | 491 |
one year after the last date of service for which reimbursement is | 492 |
sought under the claim, the third-party payer shall pay or deny | 493 |
the claim not later than ninety days after receipt of the claim. | 494 |
If the claim is denied, the third-party payer shall notify the | 495 |
provider and the beneficiary. The notice shall state, with | 496 |
specificity, why the third-party payer denied the claim. | 497 |
Sec. 3901.386. (A) Notwithstanding
section 1751.13 or | 533 |
division
(I)(2) of section 3923.04 of
the Revised
Code, a | 534 |
reimbursement contract
entered into or renewed on or after
June | 535 |
29, 1988, between a
third-party payer and a hospital shall provide | 536 |
that
reimbursement for any service provided by a hospital pursuant | 537 |
to
a reimbursement contract and covered under a benefits contract | 538 |
shall be made directly to the hospital. | 539 |
(B) If the
third-party payer and the hospital have not | 540 |
entered into a
contract regarding the provision and reimbursement | 541 |
of covered
services, the third-party payer shall accept and honor | 542 |
a
completed and validly executed assignment of benefits with a | 543 |
hospital by a beneficiary, except when the third-party payer has | 544 |
notified the hospital in writing of the conditions under which
the | 545 |
third-party payer will not accept and honor an assignment of | 546 |
benefits. Such notice shall be made annually. | 547 |
(B) A third-party payer may recover the amount of any
part | 571 |
of a payment that the third-party payer determines to be an | 572 |
overpayment if the recovery process is initiated not later than | 573 |
two years after the payment was made to the provider. The | 574 |
third-party payer shall
inform the provider of its determination | 575 |
of overpayment by providing notice in accordance with division (C) | 576 |
of this section. The
third-party payer shall give the provider an | 577 |
opportunity to appeal the
determination.
If the provider fails | 578 |
to respond to the notice sooner than thirty days after the notice | 579 |
is made, elects not to appeal the determination, or appeals the | 580 |
determination but the appeal is not
upheld, the third-party payer | 581 |
may initiate recovery of the
overpayment. | 582 |
When a provider has failed to make a timely response to the | 583 |
notice of the third-party payer's determination of overpayment, | 584 |
the third-party payer may recover the overpayment by deducting the | 585 |
amount of the overpayment from other payments the third-party | 586 |
payer owes the provider or by taking action pursuant to any other | 587 |
remedy available under the Revised Code. When a provider elects | 588 |
not to appeal a determination of overpayment or appeals the | 589 |
determination but the appeal is not upheld, the third-party payer | 590 |
shall
permit a provider to repay the amount by making one or more | 591 |
direct
payments
to the third-party payer or by having the
amount | 592 |
deducted
from
other
payments the third-party payer owes the | 593 |
provider.
| 594 |
Sec. 3901.3812. (A) If, after completion of an examination | 664 |
involving information collected from a six-month period, the | 665 |
superintendent finds that a third-party payer has committed a | 666 |
series of violations that, taken together, constitutes a | 667 |
consistent pattern or practice of violating division (A) of | 668 |
section 3901.3811 of the Revised Code, the superintendent may | 669 |
impose on the third-party payer any of the administrative remedies | 670 |
specified in division (B) of this section. In making a finding | 671 |
under this division, the superintendent shall use the compliance | 672 |
standards recommended by the national association of insurance | 673 |
commissioners. | 674 |
Before imposing an administrative remedy, the superintendent | 675 |
shall provide written notice to the third-party payer informing | 676 |
the third-party payer of the reasons for the superintendent's | 677 |
finding, the administrative remedy the superintendent proposes to | 678 |
impose, and the opportunity to submit a written request for an | 679 |
administrative hearing regarding the finding and proposed remedy. | 680 |
If the third-party payer requests a hearing, the superintendent | 681 |
shall conduct the hearing in accordance with Chapter 119. of the | 682 |
Revised Code not later than fifteen days after receipt of the | 683 |
request. | 684 |
(2) For purposes of levying a fine under division (B)(1)(a) | 699 |
of this section, a finding by the superintendent that a series of | 700 |
violations have been committed constitutes a single offense. For | 701 |
a first offense, the superintendent may levy a fine of not more | 702 |
than one hundred thousand dollars. For a second offense that | 703 |
occurs on or earlier than six years from the first offense, the | 704 |
superintendent may levy a fine of not less than fifty thousand | 705 |
dollars nor more than two hundred thousand dollars. For a third | 706 |
or additional offense that occurs on or earlier than six years | 707 |
after a first offense, the superintendent may levy a fine of not | 708 |
less than one hundred thousand dollars nor more than three hundred | 709 |
thousand dollars. In determining the amount of a fine to be | 710 |
levied within the specified limits, the superintendent shall | 711 |
consider the following factors: | 712 |
(C) "Provider"
has the same meaning as in division (A)(6)
of | 780 |
section 3901.38 of the Revised Code
means a hospital, nursing | 781 |
home, physician, podiatrist, dentist, pharmacist, chiropractor, or | 782 |
other licensed health care provider entitled to reimbursement by a | 783 |
third-party payer for services rendered to a beneficiary under a | 784 |
benefits contract. | 785 |
Sec. 3902.22. The superintendent of insurance shall
develop | 798 |
a standard claim form
and standard proof of loss to be used by all | 799 |
third-party
payers for reimbursement of health care services and | 800 |
supplies, taking into consideration the
special needs of, and | 801 |
differences between, third-party payers. The standard
claim form | 802 |
and standard proof of loss shall be prescribed in rules the | 803 |
superintendent shall adopt in accordance with Chapter
119. of the | 804 |
Revised Code. The superintendent may prescribe a separate claim | 805 |
form for each third-party payer. If a national
standard claim | 806 |
form
and
standard proof of loss is established by the sickness and | 807 |
accident insurance industry, the superintendent shall amend the | 808 |
rules to comply with the national standards. The standard claim | 809 |
form shall
include a method to specify the license numbers of | 810 |
physical therapists and
other health care professionals rendering | 811 |
services designated as physical
therapy, as required under section | 812 |
4755.56 of the Revised Code. | 813 |
(B) If a beneficiary identifies on the billing statement
of | 828 |
a provider or hospital any item or service for which the | 829 |
beneficiary was overcharged by more than five hundred dollars and | 830 |
the beneficiary notifies the third-party payer of the error at
any | 831 |
time after the thirty-day period immediately following the
date on | 832 |
which the third-party payer makes payment to the provider
or | 833 |
hospital for the item or service, the provider or hospital
shall | 834 |
refund to the beneficiary an amount equal to fifteen per
cent of | 835 |
the amount overcharged. | 836 |
Section 3. Sections 3901.38, 3901.381, 3901.382, 3901.383, | 845 |
3901.384, 3901.385, 3901.386, 3901.387, 3901.388, 3901.389, | 846 |
3901.3810, 3901.3811, 3901.3812, 3901.3813, 3901.3814, 3902.21, | 847 |
3902.22, and
3902.23 of the Revised Code, as
amended, enacted,
or | 848 |
repealed and
reenacted by this act, apply
to
any claim for | 849 |
payment for health care
services
that is submitted to
a | 850 |
third-party payer on or after
the effective
date of this act. | 851 |