As Reported by the Senate Judiciary--Civil Justice Committee

127th General Assembly Regular Session 2007-2008

Sub. H. B. No. 125

Representative Huffman 

Cosponsors: Representatives DeGeeter, Seitz, McGregor, J., Schneider, Latta, Adams, Gibbs, Setzer, Oelslager, Uecker, McGregor, R., Stewart, J., Stebelton, Fessler, Barrett, Wagoner, Celeste, Reinhard, Widener, Blessing, Book, Carmichael, Lundy, Hughes, Core, Dodd, Batchelder, Boyd, Budish, Chandler, Collier, Distel, Driehaus, Dyer, Evans, Flowers, Goyal, Hagan, J., Healy, Koziura, Letson, Luckie, Otterman, Patton, Yuko 

Senators Goodman, Seitz 

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A BILL

To amend sections 1751.13, 1753.01, 1753.07, 1753.09,

1

2317.54, 3701.741, 3702.51, and 5111.17, to enact

2

sections 3721.042, 3963.01 to 3963.11, and to

3

repeal sections 1753.03, 1753.04, 1753.05, and

4

1753.08 of the Revised Code to establish

5

certain uniform contract provisions between

6

health care providers and contracting entities,

7

to establish standardized credentialing, to

8

require the Department of Job and Family

9

Services to allow managed care plans to use

10

providers to render care, to modify the fees

11

for electronic copies of certain medical records

12

and allow an authorized person to obtain one

13

copy of a patient's medical record without

14

charge, to exempt a nursing home that is a

15

converted county or district home from

16

administrative rules regarding the toilet rooms

17

and dining and recreation areas of nursing homes

18

if certain other requirements are met, to create a

19

Joint Legislative Study Commission on Most

20

Favored Nation Clauses in Health Care

21

Contracts, and to create an Advisory Committee on

22

Eligibility and Real Time Claim Adjudication.

23

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1. That sections 1751.13, 1753.01, 1753.07, 1753.09,	24
2317.54, 3701.741, 3702.51, and 5111.17 be amended and sections	25
3721.042, 3963.01, 3963.02, 3963.03, 3963.04, 3963.05, 3963.06,	26
3963.07, 3963.08, 3963.09, 3963.10, and 3963.11 of the Revised	27
Code be enacted to read as follows:	28

Sec. 1751.13.  (A)(1)(a) A health insuring corporation shall,	29
either directly or indirectly, enter into contracts for the	30
provision of health care services with a sufficient number and	31
types of providers and health care facilities to ensure that all	32
covered health care services will be accessible to enrollees from	33
a contracted provider or health care facility.	34

(b) A health insuring corporation shall not refuse to	35
contract with a physician for the provision of health care	36
services or refuse to recognize a physician as a specialist on the	37
basis that the physician attended an educational program or a	38
residency program approved or certified by the American	39
osteopathic association. A health insuring corporation shall not	40
refuse to contract with a health care facility for the provision	41
of health care services on the basis that the health care facility	42
is certified or accredited by the American osteopathic association	43
or that the health care facility is an osteopathic hospital as	44
defined in section 3702.51 of the Revised Code.	45

(c) Nothing in division (A)(1)(b) of this section shall be	46
construed to require a health insuring corporation to make a	47
benefit payment under a closed panel plan to a physician or health	48
care facility with which the health insuring corporation does not	49
have a contract, provided that none of the bases set forth in that	50
division are used as a reason for failing to make a benefit	51
payment.	52

(2) When a health insuring corporation is unable to provide a	53
covered health care service from a contracted provider or health	54
care facility, the health insuring corporation must provide that	55
health care service from a noncontracted provider or health care	56
facility consistent with the terms of the enrollee's policy,	57
contract, certificate, or agreement. The health insuring	58
corporation shall either ensure that the health care service be	59
provided at no greater cost to the enrollee than if the enrollee	60
had obtained the health care service from a contracted provider or	61
health care facility, or make other arrangements acceptable to the	62
superintendent of insurance.	63

(3) Nothing in this section shall prohibit a health insuring	64
corporation from entering into contracts with out-of-state	65
providers or health care facilities that are licensed, certified,	66
accredited, or otherwise authorized in that state.	67

(B)(1) A health insuring corporation shall, either directly	68
or indirectly, enter into contracts with all providers and health	69
care facilities through which health care services are provided to	70
its enrollees.	71

(2) A health insuring corporation, upon written request,	72
shall assist its contracted providers in finding stop-loss or	73
reinsurance carriers.	74

(C) A health insuring corporation shall file an annual	75
certificate with the superintendent certifying that all provider	76
contracts and contracts with health care facilities through which	77
health care services are being provided contain the following:	78

(1) A description of the method by which the provider or	79
health care facility will be notified of the specific health care	80
services for which the provider or health care facility will be	81
responsible, including any limitations or conditions on such	82
services;	83

(2) The specific hold harmless provision specifying	84
protection of enrollees set forth as follows:	85

"[Provider/Health Care Facility] agrees that in no event,	86
including but not limited to nonpayment by the health insuring	87
corporation, insolvency of the health insuring corporation, or	88
breach of this agreement, shall [Provider/Health Care Facility]	89
bill, charge, collect a deposit from, seek remuneration or	90
reimbursement from, or have any recourse against, a subscriber,	91
enrollee, person to whom health care services have been provided,	92
or person acting on behalf of the covered enrollee, for health	93
care services provided pursuant to this agreement. This does not	94
prohibit [Provider/Health Care Facility] from collecting	95
co-insurance, deductibles, or copayments as specifically provided	96
in the evidence of coverage, or fees for uncovered health care	97
services delivered on a fee-for-service basis to persons	98
referenced above, nor from any recourse against the health	99
insuring corporation or its successor."	100

(3) Provisions requiring the provider or health care facility	101
to continue to provide covered health care services to enrollees	102
in the event of the health insuring corporation's insolvency or	103
discontinuance of operations. The provisions shall require the	104
provider or health care facility to continue to provide covered	105
health care services to enrollees as needed to complete any	106
medically necessary procedures commenced but unfinished at the	107
time of the health insuring corporation's insolvency or	108
discontinuance of operations. The completion of a medically	109
necessary procedure shall include the rendering of all covered	110
health care services that constitute medically necessary follow-up	111
care for that procedure. If an enrollee is receiving necessary	112
inpatient care at a hospital, the provisions may limit the	113
required provision of covered health care services relating to	114
that inpatient care in accordance with division (D)(3) of section	115
1751.11 of the Revised Code, and may also limit such required	116
provision of covered health care services to the period ending	117
thirty days after the health insuring corporation's insolvency or	118
discontinuance of operations.	119

The provisions required by division (C)(3) of this section	120
shall not require any provider or health care facility to continue	121
to provide any covered health care service after the occurrence of	122
any of the following:	123

(a) The end of the thirty-day period following the entry of a	124
liquidation order under Chapter 3903. of the Revised Code;	125

(b) The end of the enrollee's period of coverage for a	126
contractual prepayment or premium;	127

(c) The enrollee obtains equivalent coverage with another	128
health insuring corporation or insurer, or the enrollee's employer	129
obtains such coverage for the enrollee;	130

(d) The enrollee or the enrollee's employer terminates	131
coverage under the contract;	132

(e) A liquidator effects a transfer of the health insuring	133
corporation's obligations under the contract under division (A)(8)	134
of section 3903.21 of the Revised Code.	135

(4) A provision clearly stating the rights and	136
responsibilities of the health insuring corporation, and of the	137
contracted providers and health care facilities, with respect to	138
administrative policies and programs, including, but not limited	139
to, payments systems, utilization review, quality assurance,	140
assessment, and improvement programs, credentialing,	141
confidentiality requirements, and any applicable federal or state	142
programs;	143

(5) A provision regarding the availability and	144
confidentiality of those health records maintained by providers	145
and health care facilities to monitor and evaluate the quality of	146
care, to conduct evaluations and audits, and to determine on a	147
concurrent or retrospective basis the necessity of and	148
appropriateness of health care services provided to enrollees.	149
The provision shall include terms requiring the provider or health	150
care facility to make these health records available to	151
appropriate state and federal authorities involved in assessing	152
the quality of care or in investigating the grievances or	153
complaints of enrollees, and requiring the provider or health care	154
facility to comply with applicable state and federal laws related	155
to the confidentiality of medical or health records.	156

(6) A provision that states that contractual rights and	157
responsibilities may not be assigned or delegated by the provider	158
or health care facility without the prior written consent of the	159
health insuring corporation;	160

(7) A provision requiring the provider or health care	161
facility to maintain adequate professional liability and	162
malpractice insurance. The provision shall also require the	163
provider or health care facility to notify the health insuring	164
corporation not more than ten days after the provider's or health	165
care facility's receipt of notice of any reduction or cancellation	166
of such coverage.	167

(8) A provision requiring the provider or health care	168
facility to observe, protect, and promote the rights of enrollees	169
as patients;	170

(9) A provision requiring the provider or health care	171
facility to provide health care services without discrimination on	172
the basis of a patient's participation in the health care plan,	173
age, sex, ethnicity, religion, sexual preference, health status,	174
or disability, and without regard to the source of payments made	175
for health care services rendered to a patient. This requirement	176
shall not apply to circumstances when the provider or health care	177
facility appropriately does not render services due to limitations	178
arising from the provider's or health care facility's lack of	179
training, experience, or skill, or due to licensing restrictions.	180

(10) A provision containing the specifics of any obligation	181
on the primary care provider to provide, or to arrange for the	182
provision of, covered health care services twenty-four hours per	183
day, seven days per week;	184

(11) A provision setting forth procedures for the resolution	185
of disputes arising out of the contract;	186

(12) A provision stating that the hold harmless provision	187
required by division (C)(2) of this section shall survive the	188
termination of the contract with respect to services covered and	189
provided under the contract during the time the contract was in	190
effect, regardless of the reason for the termination, including	191
the insolvency of the health insuring corporation;	192

(13) A provision requiring those terms that are used in the	193
contract and that are defined by this chapter, be used in the	194
contract in a manner consistent with those definitions.	195

This division does not apply to the coverage of beneficiaries	196
enrolled in Title XVIII of the "Social Security Act," 49 Stat. 620	197
(1935), 42 U.S.C.A. 301, as amended, pursuant to a medicare risk	198
contract or medicare cost contract, or to the coverage of	199
beneficiaries enrolled in the federal employee health benefits	200
program pursuant to 5 U.S.C.A. 8905, or to the coverage of	201
beneficiaries enrolled in Title XIX of the "Social Security Act,"	202
49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended, known as the	203
medical assistance program or medicaid, provided by the department	204
of job and family services under Chapter 5111. of the Revised	205
Code, or to the coverage of beneficiaries under any federal health	206
care program regulated by a federal regulatory body, or to the	207
coverage of beneficiaries under any contract covering officers or	208
employees of the state that has been entered into by the	209
department of administrative services.	210

(D)(1) No health insuring corporation contract with a	211
provider or health care facility shall contain any of the	212
following:	213

(a) A provision that directly or indirectly offers an	214
inducement to the provider or health care facility to reduce or	215
limit medically necessary health care services to a covered	216
enrollee;	217

(b) A provision that penalizes a provider or health care	218
facility that assists an enrollee to seek a reconsideration of the	219
health insuring corporation's decision to deny or limit benefits	220
to the enrollee;	221

(c) A provision that limits or otherwise restricts the	222
provider's or health care facility's ethical and legal	223
responsibility to fully advise enrollees about their medical	224
condition and about medically appropriate treatment options;	225

(d) A provision that penalizes a provider or health care	226
facility for principally advocating for medically necessary health	227
care services;	228

(e) A provision that penalizes a provider or health care	229
facility for providing information or testimony to a legislative	230
or regulatory body or agency. This shall not be construed to	231
prohibit a health insuring corporation from penalizing a provider	232
or health care facility that provides information or testimony	233
that is libelous or slanderous or that discloses trade secrets	234
which the provider or health care facility has no privilege or	235
permission to disclose.	236

(f) A provision that violates Chapter 3963. of the Revised	237
Code.	238

(2) Nothing in this division shall be construed to prohibit a	239
health insuring corporation from doing either of the following:	240

(a) Making a determination not to reimburse or pay for a	241
particular medical treatment or other health care service;	242

(b) Enforcing reasonable peer review or utilization review	243
protocols, or determining whether a particular provider or health	244
care facility has complied with these protocols.	245

(E) Any contract between a health insuring corporation and an	246
intermediary organization shall clearly specify that the health	247
insuring corporation must approve or disapprove the participation	248
of any provider or health care facility with which the	249
intermediary organization contracts.	250

(F) If an intermediary organization that is not a health	251
delivery network contracting solely with self-insured employers	252
subcontracts with a provider or health care facility, the	253
subcontract with the provider or health care facility shall do all	254
of the following:	255

(1) Contain the provisions required by divisions (C) and (G)	256
of this section, as made applicable to an intermediary	257
organization, without the inclusion of inducements or penalties	258
described in division (D) of this section;	259

(2) Acknowledge that the health insuring corporation is a	260
third-party beneficiary to the agreement;	261

(3) Acknowledge the health insuring corporation's role in	262
approving the participation of the provider or health care	263
facility, pursuant to division (E) of this section.	264

(G) Any provider contract or contract with a health care	265
facility shall clearly specify the health insuring corporation's	266
statutory responsibility to monitor and oversee the offering of	267
covered health care services to its enrollees.	268

(H)(1) A health insuring corporation shall maintain its	269
provider contracts and its contracts with health care facilities	270
at one or more of its places of business in this state, and shall	271
provide copies of these contracts to facilitate regulatory review	272
upon written notice by the superintendent of insurance.	273

(2) Any contract with an intermediary organization that	274
accepts compensation shall include provisions requiring the	275
intermediary organization to provide the superintendent with	276
regulatory access to all books, records, financial information,	277
and documents related to the provision of health care services to	278
subscribers and enrollees under the contract. The contract shall	279
require the intermediary organization to maintain such books,	280
records, financial information, and documents at its principal	281
place of business in this state and to preserve them for at least	282
three years in a manner that facilitates regulatory review.	283

(I)(1) A health insuring corporation shall notify its	284
affected enrollees of the termination of a contract for the	285
provision of health care services between the health insuring	286
corporation and a primary care physician or hospital, by mail,	287
within thirty days after the termination of the contract.	288

(a) Notice shall be given to subscribers of the termination	289
of a contract with a primary care physician if the subscriber, or	290
a dependent covered under the subscriber's health care coverage,	291
has received health care services from the primary care physician	292
within the previous twelve months or if the subscriber or	293
dependent has selected the physician as the subscriber's or	294
dependent's primary care physician within the previous twelve	295
months.	296

(b) Notice shall be given to subscribers of the termination	297
of a contract with a hospital if the subscriber, or a dependent	298
covered under the subscriber's health care coverage, has received	299
health care services from that hospital within the previous twelve	300
months.	301

(2) The health insuring corporation shall pay, in accordance	302
with the terms of the contract, for all covered health care	303
services rendered to an enrollee by a primary care physician or	304
hospital between the date of the termination of the contract and	305
five days after the notification of the contract termination is	306
mailed to a subscriber at the subscriber's last known address.	307

(J) Divisions (A) and (B) of this section do not apply to any	308
health insuring corporation that, on June 4, 1997, holds a	309
certificate of authority or license to operate under Chapter 1740.	310
of the Revised Code.	311

(K) Nothing in this section shall restrict the governing body	312
of a hospital from exercising the authority granted it pursuant to	313
section 3701.351 of the Revised Code.	314

Sec. 1753.01.  As used in this chapter:

315

(A) "Economic profiling" means a health insuring	316
corporation's use of economic performance data and economic	317
information in determining whether to contract with a provider for	318
the provision of covered health care services to enrollees as a	319
participating provider.	320

(B) "Basic, "basic health care services," "enrollee," "health	321
care facility," "health care services," "health insuring	322
corporation," "medical record," "person," "primary care provider,"	323
"provider," "specialty health care services," "subscriber," and	324
"supplemental health care services" have the same meanings as in	325
section 1751.01 of the Revised Code.	326

Sec. 1753.07.  (A)(1) Prior to entering into a participation	327
contract with a provider under section 1751.13 of the Revised	328
Code, a health insuring corporation shall disclose basic	329
information regarding its programs and procedures to the provider,	330
upon the provider's request. The information shall include all of	331
the following:	332

(1)(a) How a participating provider is reimbursed for the	333
participating provider's services, including the range and	334
structure of any financial risk sharing arrangements, a	335
description of any incentive plans, and, if reimbursed according	336
to a type of fee-for-service arrangement, the level of	337
reimbursement for the participating provider's services;	338

(2)(b) Insofar as division (A)(1) of section 3963.03 of the	339
Revised Code is applicable, all of the information that is	340
described in that division and is not included in division	341
(A)(1)(a) of this section.	342

(2) Prior to entering into a participation contract with a	343
provider under section 1751.13 of the Revised Code, a health	344
insuring corporation shall disclose the following information upon	345
the provider's request:	346

(a) How referrals to other participating providers or to	347
nonparticipating providers are made;	348

(3)(b) The availability of dispute resolution procedures and	349
the potential for cost to be incurred;	350

(4)(c) How a participating provider's name and address will	351
be used in marketing materials.	352

(B) A health insuring corporation shall provide all of the	353
following to a participating provider:	354

(1) Any material incorporated by reference into the	355
participation contract, that is not otherwise available as a	356
public record, if such material affects the participating	357
provider;	358

(2) Administrative manuals related to provider participation,	359
if any;	360

(3) Insofar as division (B) of section 3963.03 of the Revised	361
Code is applicable, the summary disclosure form with the	362
disclosures required under that division;	363

(4) A signed and dated copy of the final participation	364
contract.	365

(C) Nothing in this section requires a health insuring	366
corporation providing specialty health care services or	367
supplemental health care services to disclose the health insuring	368
corporation's aggregate maximum allowable fee table used to	369
determine providers' fees or fee schedules.	370

Sec. 1753.09.  (A) Except as provided in division (D) of this	371
section, prior to terminating the participation of a provider on	372
the basis of the participating provider's failure to meet the	373
health insuring corporation's standards for quality or utilization	374
in the delivery of health care services, a health insuring	375
corporation shall give the participating provider notice of the	376
reason or reasons for its decision to terminate the provider's	377
participation and an opportunity to take corrective action. The	378
health insuring corporation shall develop a performance	379
improvement plan in conjunction with the participating provider.	380
If after being afforded the opportunity to comply with the	381
performance improvement plan, the participating provider fails to	382
do so, the health insuring corporation may terminate the	383
participation of the provider.	384

(B)(1) A participating provider whose participation has been	385
terminated under division (A) of this section may appeal the	386
termination to the appropriate medical director of the health	387
insuring corporation. The medical director shall give the	388
participating provider an opportunity to discuss with the medical	389
director the reason or reasons for the termination.	390

(2) If a satisfactory resolution of a participating	391
provider's appeal cannot be reached under division (B)(1) of this	392
section, the participating provider may appeal the termination to	393
a panel composed of participating providers who have comparable or	394
higher levels of education and training than the participating	395
provider making the appeal. A representative of the participating	396
provider's specialty shall be a member of the panel, if possible.	397
This panel shall hold a hearing, and shall render its	398
recommendation in the appeal within thirty days after holding the	399
hearing. The recommendation shall be presented to the medical	400
director and to the participating provider.	401

(3) The medical director shall review and consider the	402
panel's recommendation before making a decision. The decision	403
rendered by the medical director shall be final.	404

(C) A provider's status as a participating provider shall	405
remain in effect during the appeal process set forth in division	406
(B) of this section unless the termination was based on any of the	407
reasons listed in division (D) of this section.	408

(D) Notwithstanding division (A) of this section, a	409
provider's participation may be immediately terminated if the	410
participating provider's conduct presents an imminent risk of harm	411
to an enrollee or enrollees; or if there has occurred unacceptable	412
quality of care, fraud, patient abuse, loss of clinical	413
privileges, loss of professional liability coverage, incompetence,	414
or loss of authority to practice in the participating provider's	415
field; or if a governmental action has impaired the participating	416
provider's ability to practice.	417

(E) Divisions (A) to (D) of this section apply only to	418
providers who are natural persons.	419

(F)(1) Nothing in this section prohibits a health insuring	420
corporation from rejecting a provider's application for	421
participation, or from terminating a participating provider's	422
contract, if the health insuring corporation determines that the	423
health care needs of its enrollees are being met and no need	424
exists for the provider's or participating provider's services.	425

(2) Nothing in this section shall be construed as prohibiting	426
a health insuring corporation from terminating a participating	427
provider who does not meet the terms and conditions of the	428
participating provider's contract.	429

(3) Nothing in this section shall be construed as prohibiting	430
a health insuring corporation from terminating a participating	431
provider's contract pursuant to any provision of the contract	432
described in division (E)(2) of section 3963.02 of the Revised	433
Code, except that, notwithstanding any provision of a contract	434
described in that division, this section applies to the	435
termination of a participating provider's contract for any of the	436
causes described in divisions (A), (D), and (F)(1) and (2) of	437
this section.	438

(G) The superintendent of insurance may adopt rules as	439
necessary to implement and enforce sections 1753.04 to1753.06,	440
1753.07, and 1753.09 of the Revised Code. Such rules shall be	441
adopted in accordance with Chapter 119. of the Revised Code. The	442
director of health may make recommendations to the superintendent	443
for rules necessary to implement and enforce sections 1753.04 to	444
1753.06, 1753.07, and 1753.09 of the Revised Code. In adopting any	445
rules pursuant to this division, the superintendent shall consider	446
the recommendations of the director.	447

Sec. 2317.54.  No hospital, home health agency, ambulatory	448
surgical facility, or provider of a hospice care program shall be	449
held liable for a physician's failure to obtain an informed	450
consent from the physician's patient prior to a surgical or	451
medical procedure or course of procedures, unless the physician is	452
an employee of the hospital, home health agency, ambulatory	453
surgical facility, or provider of a hospice care program.	454

Written consent to a surgical or medical procedure or course	455
of procedures shall, to the extent that it fulfills all the	456
requirements in divisions (A), (B), and (C) of this section, be	457
presumed to be valid and effective, in the absence of proof by a	458
preponderance of the evidence that the person who sought such	459
consent was not acting in good faith, or that the execution of the	460
consent was induced by fraudulent misrepresentation of material	461
facts, or that the person executing the consent was not able to	462
communicate effectively in spoken and written English or any other	463
language in which the consent is written. Except as herein	464
provided, no evidence shall be admissible to impeach, modify, or	465
limit the authorization for performance of the procedure or	466
procedures set forth in such written consent.	467

(A) The consent sets forth in general terms the nature and	468
purpose of the procedure or procedures, and what the procedures	469
are expected to accomplish, together with the reasonably known	470
risks, and, except in emergency situations, sets forth the names	471
of the physicians who shall perform the intended surgical	472
procedures.	473

(B) The person making the consent acknowledges that such	474
disclosure of information has been made and that all questions	475
asked about the procedure or procedures have been answered in a	476
satisfactory manner.	477

(C) The consent is signed by the patient for whom the	478
procedure is to be performed, or, if the patient for any reason	479
including, but not limited to, competence, infancyminority, or	480
the fact that, at the latest time that the consent is needed, the	481
patient is under the influence of alcohol, hallucinogens, or	482
drugs, lacks legal capacity to consent, by a person who has legal	483
authority to consent on behalf of such patient in such	484
circumstances, including either of the following:	485

(1) The parent, whether the parent is an adult or a minor, of	486
the parent's minor child;	487

(2) An adult whom the parent of the minor child has given	488
written authorization to consent to a surgical or medical	489
procedure or course of procedures for the parent's minor child.	490

Any use of a consent form that fulfills the requirements	491
stated in divisions (A), (B), and (C) of this section has no	492
effect on the common law rights and liabilities, including the	493
right of a physician to obtain the oral or implied consent of a	494
patient to a medical procedure, that may exist as between	495
physicians and patients on July 28, 1975.	496

As used in this section the term "hospital" has the same	497
meaning as in section 2305.113 of the Revised Code; "home health	498
agency" has the same meaning as in section 5101.61 of the Revised	499
Code; "ambulatory surgical facility" has the meaning as in	500
division (A) of section 3702.30 of the Revised Code; and "hospice	501
care program" has the same meaning as in section 3712.01 of the	502
Revised Code. The provisions of this division apply to hospitals,	503
doctors of medicine, doctors of osteopathic medicine, and doctors	504
of podiatric medicine.	505

Sec. 3701.741.  (A) Through December 31, 2008, each Each	506
health care provider and medical records company shall provide	507
copies of medical records in accordance with this section.	508

(B) Except as provided in divisions (C) and (E) of this	509
section, a health care provider or medical records company that	510
receives a request for a copy of a patient's medical record shall	511
charge not more than the amounts set forth in this section.	512

(1) If the request is made by the patient or the patient's	513
personal representative, total costs for copies and all services	514
related to those copies shall not exceed the sum of the following:	515

(a) WithExcept as provided in division (B)(1)(b) of this	516
section, with respect to data recorded on paper or electronically,	517
the following amounts:	518

(i) Two dollars and fiftyseventy-four cents per page for the	519
first ten pages;	520

(ii) Fifty-oneFifty-seven cents per page for pages eleven	521
through fifty;	522

(iii) TwentyTwenty-three cents per page for pages fifty-one	523
and higher;	524

(b) With respect to data resulting from an x-ray, magnetic	525
resonance imaging (MRI), or computed axial tomography (CAT) scan	526
and recorded other than on paper or film, one dollar and seventy	527
eighty-seven cents per page;	528

(c) The actual cost of any related postage incurred by the	529
health care provider or medical records company.	530

(2) If the request is made other than by the patient or the	531
patient's personal representative, total costs for copies and all	532
services related to those copies shall not exceed the sum of the	533
following:	534

(a) An initial fee of fifteensixteen dollars and thirty-five	535
eighty-four cents, which shall compensate for the records search;	536

(b) WithExcept as provided in division (B)(2)(c) of this	537
section, with respect to data recorded on paper or electronically,	538
the following amounts:	539

(i) One dollar and twoeleven cents per page for the first	540
ten pages;	541

(ii) Fifty-oneFifty-seven cents per page for pages eleven	542
through fifty;	543

(iii) TwentyTwenty-three cents per page for pages fifty-one	544
and higher.	545

(c) With respect to data resulting from an x-ray, magnetic	546
resonance imaging (MRI), or computed axial tomography (CAT) scan	547
and recorded other than on paper or film, one dollar and seventy	548
eighty-seven cents per page;	549

(d) The actual cost of any related postage incurred by the	550
health care provider or medical records company.	551

(C)(1) AOn request, a health care provider or medical	552
records company shall provide one copy of the patient's medical	553
record and one copy of any records regarding treatment performed	554
subsequent to the original request, not including copies of	555
records already provided, without charge to the following:	556

(a) The bureau of workers' compensation, in accordance with	557
Chapters 4121. and 4123. of the Revised Code and the rules adopted	558
under those chapters;	559

(b) The industrial commission, in accordance with Chapters	560
4121. and 4123. of the Revised Code and the rules adopted under	561
those chapters;	562

(c) The department of job and family services or a county	563
department of job and family services, in accordance with	564
Chapters 5101. and 5111. of the Revised Code and the rules adopted	565
under those chapters;	566

(d) The attorney general, in accordance with sections 2743.51	567
to 2743.72 of the Revised Code and any rules that may be adopted	568
under those sections;	569

(e) A patient or, patient's personal representative, or	570
authorized person if the medical record is necessary to support a	571
claim under Title II or Title XVI of the "Social Security Act," 49	572
Stat. 620 (1935), 42 U.S.C.A. 401 and 1381, as amended, and the	573
request is accompanied by documentation that a claim has been	574
filed.	575

(2) Nothing in division (C)(1) of this section requires a	576
health care provider or medical records company to provide a copy	577
without charge to any person or entity not listed in division	578
(C)(1) of this section.	579

(D) Division (C) of this section shall not be construed to	580
supersede any rule of the bureau of workers' compensation, the	581
industrial commission, or the department of job and family	582
services.	583

(E) A health care provider or medical records company may	584
enter into a contract with either of the following for the copying	585
of medical records at a fee other than as provided in division (B)	586
of this section:	587

(1) A patient, a patient's personal representative, or an	588
authorized person;	589

(2) An insurer authorized under Title XXXIX of the Revised	590
Code to do the business of sickness and accident insurance in this	591
state or health insuring corporations holding a certificate of	592
authority under Chapter 1751. of the Revised Code.	593

(F) This section does not apply to medical records the	594
copying of which is covered by section 173.20 of the Revised Code	595
or by 42 C.F.R. 483.10.	596

Sec. 3702.51.  As used in sections 3702.51 to 3702.62 of the	597
Revised Code:	598

(A) "Applicant" means any person that submits an application	599
for a certificate of need and who is designated in the application	600
as the applicant.	601

(B) "Person" means any individual, corporation, business	602
trust, estate, firm, partnership, association, joint stock	603
company, insurance company, government unit, or other entity.	604

(C) "Certificate of need" means a written approval granted by	605
the director of health to an applicant to authorize conducting a	606
reviewable activity.	607

(D) "Health service area" means a geographic region	608
designated by the director of health under section 3702.58 of the	609
Revised Code.	610

(E) "Health service" means a clinically related service, such	611
as a diagnostic, treatment, rehabilitative, or preventive service.	612

(F) "Health service agency" means an agency designated to	613
serve a health service area in accordance with section 3702.58 of	614
the Revised Code.	615

(G) "Health care facility" means:

616

(1) A hospital registered under section 3701.07 of the	617
Revised Code;	618

(2) A nursing home licensed under section 3721.02 of the	619
Revised Code, or by a political subdivision certified under	620
section 3721.09 of the Revised Code;	621

(3) A county home or a county nursing home as defined in	622
section 5155.31 of the Revised Code that is certified under Title	623
XVIII or XIX of the "Social Security Act," 49 Stat. 620 (1935), 42	624
U.S.C.A. 301, as amended;	625

(4) A freestanding dialysis center;

626

(5) A freestanding inpatient rehabilitation facility;

627

(6) An ambulatory surgical facility;

628

(7) A freestanding cardiac catheterization facility;

629

(8) A freestanding birthing center;

630

(9) A freestanding or mobile diagnostic imaging center;

631

(10) A freestanding radiation therapy center.

632

A health care facility does not include the offices of	633
private physicians and dentists whether for individual or group	634
practice, residential facilities licensed under section 5123.19 of	635
the Revised Code, or an institution for the sick that is operated	636
exclusively for patients who use spiritual means for healing and	637
for whom the acceptance of medical care is inconsistent with their	638
religious beliefs, accredited by a national accrediting	639
organization, exempt from federal income taxation under section	640
501 of the Internal Revenue Code of 1986, 100 Stat. 2085, 26	641
U.S.C.A. 1, as amended, and providing twenty-four hour nursing	642
care pursuant to the exemption in division (E) of section 4723.32	643
of the Revised Code from the licensing requirements of Chapter	644
4723. of the Revised Code.	645

(H) "Medical equipment" means a single unit of medical	646
equipment or a single system of components with related functions	647
that is used to provide health services.	648

(I) "Third-party payer" means a health insuring corporation	649
licensed under Chapter 1751. of the Revised Code, a health	650
maintenance organization as defined in division (K) of this	651
section, an insurance company that issues sickness and accident	652
insurance in conformity with Chapter 3923. of the Revised Code, a	653
state-financed health insurance program under Chapter 3701.,	654
4123., or 5111. of the Revised Code, or any self-insurance plan.	655

(J) "Government unit" means the state and any county,	656
municipal corporation, township, or other political subdivision of	657
the state, or any department, division, board, or other agency of	658
the state or a political subdivision.	659

(K) "Health maintenance organization" means a public or	660
private organization organized under the law of any state that is	661
qualified under section 1310(d) of Title XIII of the "Public	662
Health Service Act," 87 Stat. 931 (1973), 42 U.S.C. 300e-9.	663

(L) "Existing health care facility" means either of the	664
following:	665

(1) A health care facility that is licensed or otherwise	666
authorized to operate in this state in accordance with applicable	667
law, including a county home or a county nursing home that is	668
certified as of February 1, 2008, under Title XVIII or Title XIX	669
of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C. 301,	670
as amended, is staffed and equipped to provide health care	671
services, and is actively providing health services;	672

(2) A health care facility that is licensed or otherwise	673
authorized to operate in this state in accordance with applicable	674
law, including a county home or a county nursing home that is	675
certified as of February 1, 2008, under Title XVIII or Title XIX	676
of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C. 301,	677
as amended, or that has beds registered under section 3701.07 of	678
the Revised Code as skilled nursing beds or long-term care beds	679
and has provided services for at least three hundred sixty-five	680
consecutive days within the twenty-four months immediately	681
preceding the date a certificate of need application is filed with	682
the director of health.	683

(M) "State" means the state of Ohio, including, but not	684
limited to, the general assembly, the supreme court, the offices	685
of all elected state officers, and all departments, boards,	686
offices, commissions, agencies, institutions, and other	687
instrumentalities of the state of Ohio. "State" does not include	688
political subdivisions.	689

(N) "Political subdivision" means a municipal corporation,	690
township, county, school district, and all other bodies corporate	691
and politic responsible for governmental activities only in	692
geographic areas smaller than that of the state to which the	693
sovereign immunity of the state attaches.	694

(O) "Affected person" means:

695

(1) An applicant for a certificate of need, including an	696
applicant whose application was reviewed comparatively with the	697
application in question;	698

(2) The person that requested the reviewability ruling in	699
question;	700

(3) Any person that resides or regularly uses health care	701
facilities within the geographic area served or to be served by	702
the health care services that would be provided under the	703
certificate of need or reviewability ruling in question;	704

(4) Any health care facility that is located in the health	705
service area where the health care services would be provided	706
under the certificate of need or reviewability ruling in question;	707

(5) Third-party payers that reimburse health care facilities	708
for services in the health service area where the health care	709
services would be provided under the certificate of need or	710
reviewability ruling in question;	711

(6) Any other person who testified at a public hearing held	712
under division (B) of section 3702.52 of the Revised Code or	713
submitted written comments in the course of review of the	714
certificate of need application in question.	715

(P) "Osteopathic hospital" means a hospital registered under	716
section 3701.07 of the Revised Code that advocates osteopathic	717
principles and the practice and perpetuation of osteopathic	718
medicine by doing any of the following:	719

(1) Maintaining a department or service of osteopathic	720
medicine or a committee on the utilization of osteopathic	721
principles and methods, under the supervision of an osteopathic	722
physician;	723

(2) Maintaining an active medical staff, the majority of	724
which is comprised of osteopathic physicians;	725

(3) Maintaining a medical staff executive committee that has	726
osteopathic physicians as a majority of its members.	727

(Q) "Ambulatory surgical facility" has the same meaning as in	728
section 3702.30 of the Revised Code.	729

(R) Except as otherwise provided in division (T) of this	730
section, and until the termination date specified in section	731
3702.511 of the Revised Code, "reviewable activity" means any of	732
the following:	733

(1) The addition by any person of any of the following health	734
services, regardless of the amount of operating costs or capital	735
expenditures:	736

(a) A heart, heart-lung, lung, liver, kidney, bowel,	737
pancreas, or bone marrow transplantation service, a stem cell	738
harvesting and reinfusion service, or a service for	739
transplantation of any other organ unless transplantation of the	740
organ is designated by public health council rule not to be a	741
reviewable activity;	742

(b) A cardiac catheterization service;

743

(c) An open-heart surgery service;

744

(d) Any new, experimental medical technology that is	745
designated by rule of the public health council.	746

(2) The acceptance of high-risk patients, as defined in rules	747
adopted under section 3702.57 of the Revised Code, by any cardiac	748
catheterization service that was initiated without a certificate	749
of need pursuant to division (R)(3)(b) of the version of this	750
section in effect immediately prior to April 20, 1995;	751

(3)(a) The establishment, development, or construction of a	752
new health care facility other than a new long-term care facility	753
or a new hospital;	754

(b) The establishment, development, or construction of a new	755
hospital or the relocation of an existing hospital;	756

(c) The relocation of hospital beds, other than long-term	757
care, perinatal, or pediatric intensive care beds, into or out of	758
a rural area.	759

(4)(a) The replacement of an existing hospital;

760

(b) The replacement of an existing hospital obstetric or	761
newborn care unit or freestanding birthing center.	762

(5)(a) The renovation of a hospital that involves a capital	763
expenditure, obligated on or after June 30, 1995, of five million	764
dollars or more, not including expenditures for equipment,	765
staffing, or operational costs. For purposes of division (R)(5)(a)	766
of this section, a capital expenditure is obligated:	767

(i) When a contract enforceable under Ohio law is entered	768
into for the construction, acquisition, lease, or financing of a	769
capital asset;	770

(ii) When the governing body of a hospital takes formal	771
action to commit its own funds for a construction project	772
undertaken by the hospital as its own contractor;	773

(iii) In the case of donated property, on the date the gift	774
is completed under applicable Ohio law.	775

(b) The renovation of a hospital obstetric or newborn care	776
unit or freestanding birthing center that involves a capital	777
expenditure of five million dollars or more, not including	778
expenditures for equipment, staffing, or operational costs.	779

(6) Any change in the health care services, bed capacity, or	780
site, or any other failure to conduct the reviewable activity in	781
substantial accordance with the approved application for which a	782
certificate of need was granted, if the change is made prior to	783
the date the activity for which the certificate was issued ceases	784
to be a reviewable activity;	785

(7) Any of the following changes in perinatal bed capacity or	786
pediatric intensive care bed capacity:	787

(a) An increase in bed capacity;

788

(b) A change in service or service-level designation of	789
newborn care beds or obstetric beds in a hospital or freestanding	790
birthing center, other than a change of service that is provided	791
within the service-level designation of newborn care or obstetric	792
beds as registered by the department of health;	793

(c) A relocation of perinatal or pediatric intensive care	794
beds from one physical facility or site to another, excluding the	795
relocation of beds within a hospital or freestanding birthing	796
center or the relocation of beds among buildings of a hospital or	797
freestanding birthing center at the same site.	798

(8) The expenditure of more than one hundred ten per cent of	799
the maximum expenditure specified in a certificate of need;	800

(9) Any transfer of a certificate of need issued prior to	801
April 20, 1995, from the person to whom it was issued to another	802
person before the project that constitutes a reviewable activity	803
is completed, any agreement that contemplates the transfer of a	804
certificate of need issued prior to that date upon completion of	805
the project, and any transfer of the controlling interest in an	806
entity that holds a certificate of need issued prior to that date.	807
However, the transfer of a certificate of need issued prior to	808
that date or agreement to transfer such a certificate of need from	809
the person to whom the certificate of need was issued to an	810
affiliated or related person does not constitute a reviewable	811
transfer of a certificate of need for the purposes of this	812
division, unless the transfer results in a change in the person	813
that holds the ultimate controlling interest in the certificate of	814
need.	815

(10)(a) The acquisition by any person of any of the following	816
medical equipment, regardless of the amount of operating costs or	817
capital expenditure:	818

(i) A cobalt radiation therapy unit;

819

(ii) A linear accelerator;

820

(iii) A gamma knife unit.

821

(b) The acquisition by any person of medical equipment with a	822
cost of two million dollars or more. The cost of acquiring medical	823
equipment includes the sum of the following:	824

(i) The greater of its fair market value or the cost of its	825
lease or purchase;	826

(ii) The cost of installation and any other activities	827
essential to the acquisition of the equipment and its placement	828
into service.	829

(11) The addition of another cardiac catheterization	830
laboratory to an existing cardiac catheterization service.	831

(S) Except as provided in division (T) of this section,	832
"reviewable activity" also means any of the following activities,	833
none of which are subject to a termination date:	834

(1) The establishment, development, or construction of a new	835
long-term care facility;	836

(2) The replacement of an existing long-term care facility;

837

(3) The renovation of a long-term care facility that involves	838
a capital expenditure of two million dollars or more, not	839
including expenditures for equipment, staffing, or operational	840
costs;	841

(4) Any of the following changes in long-term care bed	842
capacity:	843

(a) An increase in bed capacity;

844

(b) A relocation of beds from one physical facility or site	845
to another, excluding the relocation of beds within a long-term	846
care facility or among buildings of a long-term care facility at	847
the same site;	848

(c) A recategorization of hospital beds registered under	849
section 3701.07 of the Revised Code from another registration	850
category to skilled nursing beds or long-term care beds.	851

(5) Any change in the health services, bed capacity, or site,	852
or any other failure to conduct the reviewable activity in	853
substantial accordance with the approved application for which a	854
certificate of need concerning long-term care beds was granted, if	855
the change is made within five years after the implementation of	856
the reviewable activity for which the certificate was granted;	857

(6) The expenditure of more than one hundred ten per cent of	858
the maximum expenditure specified in a certificate of need	859
concerning long-term care beds;	860

(7) Any transfer of a certificate of need that concerns	861
long-term care beds and was issued prior to April 20, 1995, from	862
the person to whom it was issued to another person before the	863
project that constitutes a reviewable activity is completed, any	864
agreement that contemplates the transfer of such a certificate of	865
need upon completion of the project, and any transfer of the	866
controlling interest in an entity that holds such a certificate of	867
need. However, the transfer of a certificate of need that concerns	868
long-term care beds and was issued prior to April 20, 1995, or	869
agreement to transfer such a certificate of need from the person	870
to whom the certificate was issued to an affiliated or related	871
person does not constitute a reviewable transfer of a certificate	872
of need for purposes of this division, unless the transfer results	873
in a change in the person that holds the ultimate controlling	874
interest in the certificate of need.	875

(T) "Reviewable activity" does not include any of the	876
following activities:	877

(1) Acquisition of computer hardware or software;

878

(2) Acquisition of a telephone system;

879

(3) Construction or acquisition of parking facilities;

880

(4) Correction of cited deficiencies that are in violation of	881
federal, state, or local fire, building, or safety laws and rules	882
and that constitute an imminent threat to public health or safety;	883

(5) Acquisition of an existing health care facility that does	884
not involve a change in the number of the beds, by service, or in	885
the number or type of health services;	886

(6) Correction of cited deficiencies identified by	887
accreditation surveys of the joint commission on accreditation of	888
healthcare organizations or of the American osteopathic	889
association;	890

(7) Acquisition of medical equipment to replace the same or	891
similar equipment for which a certificate of need has been issued	892
if the replaced equipment is removed from service;	893

(8) Mergers, consolidations, or other corporate	894
reorganizations of health care facilities that do not involve a	895
change in the number of beds, by service, or in the number or type	896
of health services;	897

(9) Construction, repair, or renovation of bathroom	898
facilities;	899

(10) Construction of laundry facilities, waste disposal	900
facilities, dietary department projects, heating and air	901
conditioning projects, administrative offices, and portions of	902
medical office buildings used exclusively for physician services;	903

(11) Acquisition of medical equipment to conduct research	904
required by the United States food and drug administration or	905
clinical trials sponsored by the national institute of health. Use	906
of medical equipment that was acquired without a certificate of	907
need under division (T)(11) of this section and for which	908
premarket approval has been granted by the United States food and	909
drug administration to provide services for which patients or	910
reimbursement entities will be charged shall be a reviewable	911
activity.	912

(12) Removal of asbestos from a health care facility.

913

Only that portion of a project that meets the requirements of	914
division (T) of this section is not a reviewable activity.	915

(U) "Small rural hospital" means a hospital that is located	916
within a rural area, has fewer than one hundred beds, and to which	917
fewer than four thousand persons were admitted during the most	918
recent calendar year.	919

(V) "Children's hospital" means any of the following:

920

(1) A hospital registered under section 3701.07 of the	921
Revised Code that provides general pediatric medical and surgical	922
care, and in which at least seventy-five per cent of annual	923
inpatient discharges for the preceding two calendar years were	924
individuals less than eighteen years of age;	925

(2) A distinct portion of a hospital registered under section	926
3701.07 of the Revised Code that provides general pediatric	927
medical and surgical care, has a total of at least one hundred	928
fifty registered pediatric special care and pediatric acute care	929
beds, and in which at least seventy-five per cent of annual	930
inpatient discharges for the preceding two calendar years were	931
individuals less than eighteen years of age;	932

(3) A distinct portion of a hospital, if the hospital is	933
registered under section 3701.07 of the Revised Code as a	934
children's hospital and the children's hospital meets all the	935
requirements of division (V)(1) of this section.	936

(W) "Long-term care facility" means any of the following:

937

(1) A nursing home licensed under section 3721.02 of the	938
Revised Code or by a political subdivision certified under section	939
3721.09 of the Revised Code;	940

(2) The portion of any facility, including a county home or	941
county nursing home, that is certified as a skilled nursing	942
facility or a nursing facility under Title XVIII or XIX of the	943
"Social Security Act";	944

(3) The portion of any hospital that contains beds registered	945
under section 3701.07 of the Revised Code as skilled nursing beds	946
or long-term care beds.	947

(X) "Long-term care bed" means a bed in a long-term care	948
facility.	949

(Y) "Perinatal bed" means a bed in a hospital that is	950
registered under section 3701.07 of the Revised Code as a newborn	951
care bed or obstetric bed, or a bed in a freestanding birthing	952
center.	953

(Z) "Freestanding birthing center" means any facility in	954
which deliveries routinely occur, regardless of whether the	955
facility is located on the campus of another health care facility,	956
and which is not licensed under Chapter 3711. of the Revised Code	957
as a level one, two, or three maternity unit or a limited	958
maternity unit.	959

(AA)(1) "Reviewability ruling" means a ruling issued by the	960
director of health under division (A) of section 3702.52 of the	961
Revised Code as to whether a particular proposed project is or is	962
not a reviewable activity.	963

(2) "Nonreviewability ruling" means a ruling issued under	964
that division that a particular proposed project is not a	965
reviewable activity.	966

(BB)(1) "Metropolitan statistical area" means an area of this	967
state designated a metropolitan statistical area or primary	968
metropolitan statistical area in United States office of	969
management and budget bulletin No.no. 93-17, June 30, 1993, and	970
its attachments.	971

(2) "Rural area" means any area of this state not located	972
within a metropolitan statistical area.	973

(CC) "County nursing home" has the same meaning as in section	974
5155.31 of the Revised Code.	975

Sec. 3721.042.  The director of health may not deny a nursing	976
home license to a facility seeking a license under this chapter as	977
a nursing home on the grounds that the facility does not satisfy a	978
requirement established in rules adopted under section 3721.04 of	979
the Revised Code regarding the toilet rooms and dining and	980
recreational areas of nursing homes if all of the following	981
requirements are met:	982

(A) The facility seeks a license under this chapter because	983
it is a county home or district home being sold under section	984
5155.31 of the Revised Code to a person who may not operate the	985
facility without a nursing home license under this chapter.	986

(B) The requirement would not have applied to the facility	987
had the facility been a nursing home first licensed under this	988
chapter before October 20, 2001.	989

(C) The facility was a nursing facility, as defined in	990
section 5111.20 of the Revised Code, on the date immediately	991
preceding the date the facility is sold to the person seeking the	992
license.	993

Sec. 3963.01. As used in this chapter:

994

(A) "Affiliate" means any person or entity that has ownership	995
or control of a contracting entity, is owned or controlled by a	996
contracting entity, or is under common ownership or control with a	997
contracting entity.	998

(B) "Basic health care services" has the same meaning as in	999
division (A) of section 1751.01 of the Revised Code, except that	1000
it does not include any services listed in that division that are	1001
provided by a pharmacist or nursing home.	1002

(C) "Contracting entity" means any person that has a primary	1003
business purpose of contracting with participating providers for	1004
the delivery of health care services.	1005

(D) "Credentialing" means the process of assessing and	1006
validating the qualifications of a provider applying to be	1007
approved by a contracting entity to provide basic health care	1008
services, specialty health care services, or supplemental health	1009
care services to enrollees.	1010

(E) "Edit" means adjusting one or more procedure codes billed	1011
by a participating provider on a claim for payment or a practice	1012
that results in any of the following:	1013

(1) Payment for some, but not all of the procedure codes	1014
originally billed by a participating provider;	1015

(2) Payment for a different procedure code than the procedure	1016
code originally billed by a participating provider;	1017

(3) A reduced payment as a result of services provided to an	1018
enrollee that are claimed under more than one procedure code on	1019
the same service date.	1020

(F) "Electronic claims transport" means to accept and	1021
digitize claims or to accept claims already digitized, to place	1022
those claims into a format that complies with the electronic	1023
transaction standards issued by the United States department of	1024
health and human services pursuant to the "Health Insurance	1025
Portability and Accountability Act of 1996," 110 Stat. 1955, 42	1026
U.S.C. 1320d, et seq., as those electronic standards are	1027
applicable to the parties and as those electronic standards are	1028
updated from time to time, and to electronically transmit those	1029
claims to the appropriate contracting entity, payer, or	1030
third-party administrator.	1031

(G) "Enrollee" means any person eligible for health care	1032
benefits under a health benefit plan, including an eligible	1033
recipient of medicaid under Chapter 5111. of the Revised Code, and	1034
includes all of the following terms:	1035

(1) "Enrollee" and "subscriber" as defined by section 1751.01	1036
of the Revised Code;	1037

(2) "Member" as defined by section 1739.01 of the Revised	1038
Code;	1039

(3) "Insured" and "plan member" pursuant to Chapter 3923. of	1040
the Revised Code;	1041

(4) "Beneficiary" as defined by section 3901.38 of the	1042
Revised Code.	1043

(H) "Health care contract" means a contract entered into,	1044
materially amended, or renewed between a contracting entity and	1045
a participating provider for the delivery of basic health care	1046
services, specialty health care services, or supplemental health	1047
care services to enrollees.	1048

(I) "Health care services" means basic health care services,	1049
specialty health care services, and supplemental health care	1050
services.	1051

(J) "Material amendment" means an amendment to a health care	1052
contract that decreases the participating provider's payment or	1053
compensation, changes the administrative procedures in a way that	1054
may reasonably be expected to significantly increase the	1055
provider's administrative expenses, or adds a new product. A	1056
material amendment does not include any of the following:	1057

(1) A decrease in payment or compensation resulting solely	1058
from a change in a published fee schedule upon which the payment	1059
or compensation is based and the date of applicability is clearly	1060
identified in the contract;	1061

(2) A decrease in payment or compensation that was	1062
anticipated under the terms of the contract, if the amount and	1063
date of applicability of the decrease is clearly identified in the	1064
contract;	1065

(3) An administrative change that may significantly increase	1066
the provider's administrative expense, the specific applicability	1067
of which is clearly identified in the contract;	1068

(4) Changes to an existing prior authorization,	1069
precertification, notification, or referral program that do not	1070
substantially increase the provider's administrative expense;	1071

(5) Changes to an edit program or to specific edits if the	1072
participating provider is provided notice of the changes pursuant	1073
to division (A)(1) of section 3963.04 of the Revised Code and the	1074
notice includes information sufficient for the provider to	1075
determine the effect of the change;	1076

(6) Changes to a health care contract described in division	1077
(B) of section 3963.04 of the Revised Code.	1078

(K) "Participating provider" means a provider that has a	1079
health care contract with a contracting entity and is entitled to	1080
reimbursement for health care services rendered to an enrollee	1081
under the health care contract.	1082

(L) "Payer" means any person that assumes the financial risk	1083
for the payment of claims under a health care contract or the	1084
reimbursement for health care services provided to enrollees by	1085
participating providers pursuant to a health care contract.	1086

(M) "Primary enrollee" means a person who is responsible for	1087
making payments for participation in a health care plan or an	1088
enrollee whose employment or other status is the basis of	1089
eligibility for enrollment in a health care plan.	1090

(N) "Procedure codes" includes the American medical	1091
association's current procedural terminology code, the American	1092
dental association's current dental terminology, and the centers	1093
for medicare and medicaid services health care common procedure	1094
coding system.	1095

(O) "Product" means one of the following types of categories	1096
of coverage for which a participating provider may be obligated	1097
to provide health care services pursuant to a health care	1098
contract:	1099

(1) A health maintenance organization or other product	1100
provided by a health insuring corporation;	1101

(2) A preferred provider organization;

1102

(3) Medicare;

1103

(4) Medicaid or the children's buy-in program established	1104
under section 5101.5211 to 5101.5216 of the Revised Code;	1105

(5) Workers' compensation.

1106

(P) "Provider" means a physician, podiatrist, dentist,	1107
chiropractor, optometrist, psychologist, physician assistant,	1108
advanced practice nurse, occupational therapist, massage	1109
therapist, physical therapist, professional counselor,	1110
professional clinical counselor, hearing aid dealer, orthotist,	1111
prosthetist, home health agency, hospice care program, or	1112
hospital, or a provider organization or physician-hospital	1113
organization that is acting exclusively as an administrator on	1114
behalf of a provider to facilitate the provider's participation in	1115
health care contracts. "Provider" does not mean a pharmacist,	1116
pharmacy, nursing home, or a provider organization or	1117
physician-hospital organization that leases the provider	1118
organization's or physician-hospital organization's network to a	1119
third party or contracts directly with employers or health and	1120
welfare funds.	1121

(Q) "Specialty health care services" has the same meaning as	1122
in section 1751.01 of the Revised Code, except that it does not	1123
include any services listed in division (B) of section 1751.01 of	1124
the Revised Code that are provided by a pharmacist or a nursing	1125
home.	1126

(R) "Supplemental health care services" has the same meaning	1127
as in division (B) of section 1751.01 of the Revised Code, except	1128
that it does not include any services listed in that division that	1129
are provided by a pharmacist or nursing home.	1130

Sec. 3963.02. (A)(1) No contracting entity shall sell, rent,	1131
or give a third party the contracting entity's rights to a	1132
participating provider's services pursuant to the contracting	1133
entity's health care contract with the participating provider	1134
unless one of the following applies:	1135

(a) The third party accessing the participating provider's	1136
services under the health care contract is an employer or other	1137
entity providing coverage for health care services to its	1138
employees or members, and that employer or entity has a contract	1139
with the contracting entity or its affiliate for the	1140
administration or processing of claims for payment for services	1141
provided pursuant to the health care contract with the	1142
participating provider.	1143

(b) The third party accessing the participating provider's	1144
services under the health care contract either is an affiliate or	1145
subsidiary of the contracting entity or is providing	1146
administrative services to, or receiving administrative services	1147
from, the contracting entity or an affiliate or subsidiary of the	1148
contracting entity.	1149

(c) The health care contract specifically provides that it	1150
applies to network rental arrangements and states that one purpose	1151
of the contract is selling, renting, or giving the contracting	1152
entity's rights to the services of the participating provider,	1153
including other preferred provider organizations, and the third	1154
party accessing the participating provider's services is any of	1155
the following:	1156

(i) A payer or a third-party administrator or other entity	1157
responsible for administering claims on behalf of the payer;	1158

(ii) A preferred provider organization or preferred provider	1159
network that receives access to the participating provider's	1160
services pursuant to an arrangement with the preferred provider	1161
organization or preferred provider network in a contract with the	1162
participating provider that is in compliance with division	1163
(A)(1)(c) of this section, and is required to comply with all of	1164
the terms, conditions, and affirmative obligations to which the	1165
originally contracted primary participating provider network is	1166
bound under its contract with the participating provider,	1167
including, but not limited to, obligations concerning patient	1168
steerage and the timeliness and manner of reimbursement.	1169

(iii) An entity that is engaged in the business of providing	1170
electronic claims transport between the contracting entity and the	1171
payer or third-party administrator and complies with all of the	1172
applicable terms, conditions, and affirmative obligations of the	1173
contracting entity's contract with the participating provider	1174
including, but not limited to, obligations concerning patient	1175
steerage and the timeliness and manner of reimbursement.	1176

(2) The contracting entity that sells, rents, or gives the	1177
contracting entity's rights to the participating provider's	1178
services pursuant to the contracting entity's health care contract	1179
with the participating provider as provided in division (A)(1) of	1180
this section shall do both of the following:	1181

(a) Maintain a web page that contains a listing of third	1182
parties described in divisions (A)(1)(b) and (c) of this section	1183
with whom a contracting entity contracts for the purpose of	1184
selling, renting, or giving the contracting entity's rights to	1185
the services of participating providers that is updated at least	1186
every six months and is accessible to all participating providers,	1187
or maintain a toll-free telephone number accessible to all	1188
participating providers by means of which participating providers	1189
may access the same listing of third parties;	1190

(b) Require that the third party accessing the participating	1191
provider's services through the participating provider's health	1192
care contract is obligated to comply with all of the applicable	1193
terms and conditions of the contract, including, but not limited	1194
to, the products for which the participating provider has agreed	1195
to provide services, except that a payer receiving administrative	1196
services from the contracting entity or its affiliate shall be	1197
solely responsible for payment to the participating provider.	1198

(3) Any information disclosed to a participating provider	1199
under this section shall be considered proprietary and shall not	1200
be distributed by the participating provider.	1201

(4) Except as provided in division (A)(1) of this section, no	1202
entity shall sell, rent, or give a contracting entity's rights	1203
to the participating provider's services pursuant to a health	1204
care contract.	1205

(B)(1) No contracting entity shall require, as a condition of	1206
contracting with the contracting entity, that a participating	1207
provider provide services for all of the products offered by the	1208
contracting entity.	1209

(2) Division (B)(1) of this section shall not be construed to	1210
do any of the following:	1211

(a) Prohibit any participating provider from voluntarily	1212
accepting an offer by a contracting entity to provide health care	1213
services under all of the contracting entity's products;	1214

(b) Prohibit any contracting entity from offering any	1215
financial incentive or other form of consideration specified in	1216
the health care contract for a participating provider to provide	1217
health care services under all of the contracting entity's	1218
products;	1219

(c) Require any contracting entity to contract with a	1220
participating provider to provide health care services for less	1221
than all of the contracting entity's products if the contracting	1222
entity does not wish to do so.	1223

(3)(a) Notwithstanding division (B)(2) of this section, no	1224
contracting entity shall require, as a condition of contracting	1225
with the contracting entity, that the participating provider	1226
accept any future product offering that the contracting entity	1227
makes.	1228

(b) If a participating provider refuses to accept any future	1229
product offering that the contracting entity makes, the	1230
contracting entity may terminate the health care contract based on	1231
the participating provider's refusal upon written notice to the	1232
participating provider no sooner than one hundred eighty days	1233
after the refusal.	1234

(4) Once the contracting entity and the participating	1235
provider have signed the health care contract, it is presumed that	1236
the financial incentive or other form of consideration that is	1237
specified in the health care contract pursuant to division	1238
(B)(2)(b) of this section is the financial incentive or other form	1239
of consideration that was offered by the contracting entity to	1240
induce the participating provider to enter into the contract.	1241

(C) No contracting entity shall require, as a condition of	1242
contracting with the contracting entity, that a participating	1243
provider waive or forego any right or benefit expressly conferred	1244
upon a participating provider by state or federal law. However,	1245
this division does not prohibit a contracting entity from	1246
restricting a participating provider's scope of practice for	1247
the services to be provided under the contract.	1248

(D) No health care contract shall do any of the following:

1249

(1) Prohibit any participating provider from entering into a	1250
health care contract with any other contracting entity;	1251

(2) Prohibit any contracting entity from entering into a	1252
health care contract with any other provider;	1253

(3) Preclude its use or disclosure for the purpose of	1254
enforcing this chapter or other state or federal law, except that	1255
a health care contract may require that appropriate measures be	1256
taken to preserve the confidentiality of any proprietary or	1257
trade-secret information.	1258

(E)(1) In addition to any other lawful reasons for	1259
terminating a health care contract, a health care contract may	1260
only be terminated under the circumstances described in	1261
division (A)(3) of section 3963.04 of the Revised Code.	1262

(2) If the health care contract provides for termination for	1263
cause by either party, the health care contract shall state the	1264
reasons that may be used for termination for cause, which terms	1265
shall be reasonable. Once the contracting entity and the	1266
participating provider have signed the health care contract, it is	1267
presumed that the reasons stated in the health care contract for	1268
termination for cause by either party are reasonable. Subject to	1269
division (E)(3) of this section, the health care contract shall	1270
state the time by which the parties must provide notice of	1271
termination for cause and to whom the parties shall give the	1272
notice.	1273

(3) Nothing in divisions (E)(1) and (2) of this section shall	1274
be construed as prohibiting any health insuring corporation from	1275
terminating a participating provider's contract for any of the	1276
causes described in divisions (A), (D), and (F)(1) and (2) of	1277
section 1753.09 of the Revised Code. Notwithstanding any provision	1278
in a health care contract pursuant to division (E)(2) of this	1279
section, section 1753.09 of the Revised Code applies to the	1280
termination of a participating provider's contract for any of the	1281
causes described in divisions (A), (D), and (F)(1) and (2) of	1282
section 1753.09 of the Revised Code.	1283

(4) Subject to sections 3963.01 to 3963.11 of the Revised	1284
Code, nothing in this section prohibits the termination of a	1285
health care contract without cause if the health care contract	1286
otherwise provides for termination without cause.	1287

(F)(1) Disputes among parties to a health care contract that	1288
only concern the enforcement of the contract rights conferred by	1289
section 3963.02, divisions (A) and (D) of section 3963.03, and	1290
section 3963.04 of the Revised Code are subject to a mutually	1291
agreed upon arbitration mechanism that is binding on all	1292
parties. The arbitrator may award reasonable attorney's fees and	1293
costs for arbitration relating to the enforcement of this section	1294
to the prevailing party.	1295

(2) The arbitrator shall make the arbitrator's decision in	1296
an arbitration proceeding having due regard for any applicable	1297
rules, bulletins, rulings, or decisions issued by the department	1298
of insurance or any court concerning the enforcement of the	1299
contract rights conferred by section 3963.02, divisions (A) and	1300
(D) of section 3963.03, and section 3963.04 of the Revised Code.	1301

(3) A party shall not simultaneously maintain an arbitration	1302
proceeding as described in division (F)(1) of this section and	1303
pursue a complaint with the superintendent of insurance to	1304
investigate the subject matter of the arbitration proceeding.	1305
However, if a complaint is filed with the department of	1306
insurance, the superintendent may choose to investigate the	1307
complaint or, after reviewing the complaint, advise the	1308
complainant to proceed with arbitration to resolve the complaint.	1309
The superintendent may request to receive a copy of the results	1310
of the arbitration. If the superintendent of insurance notifies	1311
an insurer or a health insuring corporation in writing that the	1312
superintendent has initiated a market conduct examination into	1313
the specific subject matter of the arbitration proceeding pending	1314
against that insurer or health insuring corporation, the	1315
arbitration proceeding shall be stayed at the request of the	1316
insurer or health insuring corporation pending the outcome of the	1317
market conduct investigation by the superintendent.	1318

Sec. 3963.03. (A) Each health care contract shall include all	1319
of the following information:	1320

(1)(a) Information sufficient for the participating provider	1321
to determine the compensation or payment terms for health care	1322
services, including all of the following, subject to division	1323
(A)(1)(b) of this section:	1324

(i) The manner of payment, such as fee-for-service,	1325
capitation, or risk;	1326

(ii) The fee schedule of procedure codes reasonably expected	1327
to be billed by a participating provider's specialty for services	1328
provided pursuant to the health care contract and the associated	1329
payment or compensation for each procedure code. A fee schedule	1330
may be provided electronically. Upon request, a contracting	1331
entity shall provide a participating provider with the fee	1332
schedule for any other procedure codes requested and a written	1333
fee schedule, that shall not be required more frequently than	1334
twice per year excluding when it is provided in connection with	1335
any change to the schedule. This requirement may be satisfied by	1336
providing a clearly understandable, readily available mechanism,	1337
such as a specific web site address, that allows a participating	1338
provider to determine the effect of procedure codes on payment or	1339
compensation before a service is provided or a claim is	1340
submitted.	1341

(iii) The effect, if any, on payment or compensation if	1342
more than one procedure code applies to the service also shall	1343
be stated. This requirement may be satisfied by providing a	1344
clearly understandable, readily available mechanism, such as a	1345
specific web site address, that allows a participating provider	1346
to determine the effect of procedure codes on payment or	1347
compensation before a service is provided or a claim is	1348
submitted.	1349

(b) If the contracting entity is unable to include the	1350
information described in division (A)(1)(a)(ii) and (iii) of this	1351
section, the contracting entity shall include both of the	1352
following types of information instead:	1353

(i) The methodology used to calculate any fee schedule, such	1354
as relative value unit system and conversion factor or percentage	1355
of billed charges. If applicable, the methodology disclosure	1356
shall include the name of any relative value unit system, its	1357
version, edition, or publication date, any applicable conversion	1358
or geographic factor, and any date by which compensation or fee	1359
schedules may be changed by the methodology as anticipated at the	1360
time of contract.	1361

(ii) The identity of any internal processing edits ,	1362
including the publisher, product name, version, and version	1363
update of any editing software.	1364

(c) If the contracting entity is not the payer and is unable	1365
to include the information described in division (A)(1)(a) or (b)	1366
of this section, then the contracting entity shall provide by	1367
telephone a readily available mechanism, such as a specific web	1368
site address, that allows the participating provider to obtain	1369
that information from the payer.	1370

(2) Any product or network for which the participating	1371
provider is to provide services;	1372

(3) The term of the health care contract;

1373

(4) A specific web site address that contains the identity of	1374
the contracting entity or payer responsible for the processing of	1375
the participating provider's compensation or payment;	1376

(5) Any internal mechanism provided by the contracting entity	1377
to resolve disputes concerning the interpretation or application	1378
of the terms and conditions of the contract. A contracting entity	1379
may satisfy this requirement by providing a clearly	1380
understandable, readily available mechanism, such as a specific	1381
web site address or an appendix, that allows a participating	1382
provider to determine the procedures for the internal mechanism to	1383
resolve those disputes.	1384

(6) A list of addenda, if any, to the contract.

1385

(B)(1) Each contracting entity shall include a summary	1386
disclosure form with a health care contract that includes all of	1387
the information specified in division (A) of this section. The	1388
information in the summary disclosure form shall refer to the	1389
location in the health care contract, whether a page number,	1390
section of the contract, appendix, or other identifiable location,	1391
that specifies the provisions in the contract to which the	1392
information in the form refers.	1393

(2) The summary disclosure form shall include all of the	1394
following statements:	1395

(a) That the form is a guide to the health care contract and	1396
that the terms and conditions of the health care contract	1397
constitute the contract rights of the parties;	1398

(b) That reading the form is not a substitute for reading the	1399
entire health care contract;	1400

(c) That by signing the health care contract, the	1401
participating provider will be bound by the contract's terms and	1402
conditions;	1403

(d) That the terms and conditions of the health care contract	1404
may be amended pursuant to section 3963.04 of the Revised Code and	1405
the participating provider is encouraged to carefully read any	1406
proposed amendments sent after execution of the contract;	1407

(e) That nothing in the summary disclosure form creates any	1408
additional rights or causes of action in favor of either party.	1409

(3) No contracting entity that includes any information in	1410
the summary disclosure form with the reasonable belief that the	1411
information is truthful or accurate shall be subject to a civil	1412
action for damages or to binding arbitration based on the summary	1413
disclosure form. Division (B)(3) of this section does not impair	1414
or affect any power of the department of insurance to enforce any	1415
applicable law.	1416

(4) The summary disclosure form described in divisions (B)(1)	1417
and (2) of this section shall be in substantially the following	1418
form:	1419

"SUMMARY DISCLOSURE FORM	1420

(1) Compensation terms

1421

(a) Manner of payment

1422

[ ] Fee for service

1423

[ ] Capitation

1424

[ ] Risk

1425

[ ] Other ............... See ...............

1426

(b) Fee schedule available at ...............

1427

(c) Fee calculation schedule available at ...............

1428

(d) Identity of internal processing edits available at	1429
...............	1430

(e) Information in (c) and (d) is not required if information	1431
in (b) is provided.	1432

(2) List of products or networks covered by this contract

1433

[ ] ...............

1434

[ ] ...............

1435

[ ] ...............

1436

[ ] ...............

1437

[ ] ...............

1438

(3) Term of this contract ...............

1439

(4) Contracting entity or payer responsible for processing	1440
payment available at ...............	1441

(5) Internal mechanism for resolving disputes regarding	1442
contract terms available at ...............	1443

(6) Addenda to contract

1444

Title           Subject

1445

(a)

1446

(b)

1447

(c)

1448

(d)

1449

(7) Telephone number to access a readily available mechanism,	1450
such as a specific web site address, to allow a participating	1451
provider to receive the information in (1) through (6) from the	1452
payer.	1453

IMPORTANT INFORMATION - PLEASE READ CAREFULLY	1454

The information provided in this Summary Disclosure Form is a	1455
guide to the attached Health Care Contract as defined in section	1456
3963.01(G) of the Ohio Revised Code. The terms and conditions of	1457
the attached Health Care Contract constitute the contract rights	1458
of the parties.	1459

Reading this Summary Disclosure Form is not a substitute for	1460
reading the entire Health Care Contract. When you sign the Health	1461
Care Contract, you will be bound by its terms and conditions.	1462
These terms and conditions may be amended over time pursuant to	1463
section 3963.04 of the Ohio Revised Code. You are encouraged to	1464
read any proposed amendments that are sent to you after execution	1465
of the Health Care Contract.	1466

Nothing in this Summary Disclosure Form creates any	1467
additional rights or causes of action in favor of either party."	1468

(C) When a contracting entity presents a proposed health care	1469
contract for consideration by a provider, the contracting entity	1470
shall provide in writing or make reasonably available the	1471
information required in division (A)(1) of this section.	1472

(D) The contracting entity shall identify any utilization	1473
management, quality improvement, or a similar program that the	1474
contracting entity uses to review, monitor, evaluate, or assess	1475
the services provided pursuant to a health care contract. The	1476
contracting entity shall disclose the policies, procedures, or	1477
guidelines of such a program applicable to a participating	1478
provider upon request by the participating provider within	1479
fourteen days after the date of the request.	1480

(E) Nothing in this section shall be construed as preventing	1481
or affecting the application of section 1753.07 of the Revised	1482
Code that would otherwise apply to a contract with a participating	1483
provider.	1484

(F) The requirements of division (C) of this section do not	1485
prohibit a contracting entity from requiring a reasonable	1486
confidentiality agreement between the provider and the contracting	1487
entity regarding the terms of the proposed health care contract.	1488
If either party violates the confidentiality agreement, a party	1489
to the confidentiality agreement may bring a civil action to	1490
enjoin the other party from continuing any act that is in	1491
violation of the confidentiality agreement, to recover damages,	1492
to terminate the contract, or to obtain any combination of	1493
relief.	1494

Sec. 3963.04. (A)(1) If an amendment to a health care	1495
contract is not a material amendment, the contracting entity	1496
shall provide the participating provider notice of the amendment	1497
at least fifteen days prior to the effective date of the	1498
amendment. The contracting entity shall provide all other	1499
notices to the participating provider pursuant to the health	1500
care contract.	1501

(2) A material amendment to a health care contract shall	1502
occur only if the contracting entity provides to the	1503
participating provider the material amendment in writing and	1504
notice of the material amendment not later than ninety days prior	1505
to the effective date of the material amendment. The notice shall	1506
be conspicuously entitled "Notice of Material Amendment to	1507
Contract."	1508

(3) If within fifteen days after receiving the material	1509
amendment and notice described in division (A)(2) of this	1510
section, the participating provider objects in writing to the	1511
material amendment, and there is no resolution of the	1512
objection, either party may terminate the health care contract	1513
upon written notice of termination provided to the other party	1514
not later than sixty days prior to the effective date of the	1515
material amendment.	1516

(4) If the participating provider does not object to the	1517
material amendment in the manner described in division (A)(3) of	1518
this section, the material amendment shall be effective as	1519
specified in the notice described in division (A)(2) of this	1520
section.	1521

(B)(1) Division (A) of this section does not apply if the	1522
delay caused by compliance with that division could result in	1523
imminent harm to an enrollee, if the material amendment of a	1524
health care contract is required by state or federal law, rule,	1525
or regulation, or if the provider affirmatively accepts the	1526
material amendment in writing and agrees to an earlier effective	1527
date than otherwise required by division (A)(2) of this section.	1528

(2) This section does not apply under any of the following	1529
circumstances:	1530

(a) The participating provider's payment or compensation is	1531
based on the current medicaid or medicare physician fee schedule,	1532
and the change in payment or compensation results solely from a	1533
change in that physician fee schedule.	1534

(b) A routine change or update of the health care contract is	1535
made in response to any addition, deletion, or revision of any	1536
service code, procedure code, or reporting code, or a pricing	1537
change is made by any third party source.	1538

For purposes of division (B)(2)(b) of this section:

1539

(i) "Service code, procedure code, or reporting code" means	1540
the current procedural terminology (CPT), current dental	1541
terminology (CDT), the healthcare common procedure coding system	1542
(HCPCS), the international classification of diseases (ICD), or	1543
the drug topics redbook average wholesale price (AWP).	1544

(ii) "Third party source" means the American medical	1545
association, American dental association, the centers for medicare	1546
and medicaid services, the national center for health statistics,	1547
the department of health and human services office of the	1548
inspector general, the Ohio department of insurance, or the Ohio	1549
department of job and family services.	1550

(C) Notwithstanding divisions (A) and (B) of this section, a	1551
health care contract may be amended by operation of law as	1552
required by any applicable state or federal law, rule, or	1553
regulation. Nothing in this section shall be construed to require	1554
the renegotiation of a health care contract that is in existence	1555
before the effective date of this section, until the time that	1556
the contract is renewed or materially amended.	1557

Sec. 3963.05. (A) The department of insurance shall prescribe	1558
the credentialing application form used by the council for	1559
affordable quality healthcare (CAQH) in electronic or paper format	1560
for physicians. The department of insurance also shall prepare	1561
the standard credentialing form for all other providers and shall	1562
make the standard credentialing form as simple, straightforward,	1563
and easy to use as possible, having due regard for those	1564
credentialing forms that are widely in use in the state by	1565
contracting entities and that best serve these goals.	1566

(B) No contracting entity shall fail to use the applicable	1567
standard credentialing form described in division (A) of this	1568
section when initially credentialing or recredentialing providers	1569
in connection with policies, health care contracts, and	1570
agreements providing basic health care services, specialty health	1571
care services, or supplemental health care services.	1572

(C) No contracting entity shall require a provider to	1573
provide any information in addition to the information required	1574
by the applicable standard credentialing form described in	1575
division (A) of this section in connection with policies, health	1576
care contracts, and agreements providing basic health care	1577
services, specialty health care services, or supplemental health	1578
care services.	1579

(D) The credentialing process described in this section does	1580
not prohibit a contracting entity from limiting the scope of any	1581
participating provider's basic health care services, specialty	1582
health care services, or supplemental health care services.	1583

(E) The requirement that the department of insurance prepare	1584
the standard credentialing form for all other providers does not	1585
include preparing the standard credentialing form for a hospital.	1586

Sec. 3963.06. (A) If a provider, upon the oral or written	1587
request of a contracting entity to submit a credentialing form,	1588
submits a credentialing form that is not complete, the contracting	1589
entity that receives the form shall notify the provider of the	1590
deficiency electronically, by facsimile, or by certified mail,	1591
return receipt requested, not later than twenty-one days after	1592
the contracting entity receives the form.	1593

(B) If a contracting entity receives any information that is	1594
inconsistent with the information given by the provider in the	1595
credentialing form, the contracting entity may request the	1596
provider to submit a written clarification of the inconsistency.	1597
The contracting entity shall send the request described in this	1598
division electronically, by facsimile, or by certified mail,	1599
return receipt requested.	1600

(C)(1) Except as otherwise provided in division (C)(2) of	1601
this section, the credentialing process under this section starts	1602
when a provider initially submits a credentialing form upon the	1603
oral or written request of a contracting entity, and the provider	1604
shall submit the credentialing form to the contracting entity	1605
electronically, by facsimile, or by certified mail, return receipt	1606
requested. Subject to division (C)(3) of this section, a	1607
contracting entity shall complete the credentialing process not	1608
later than ninety days after the contracting entity receives	1609
that credentialing form from the provider. The contracting entity	1610
shall allow the provider to submit a credentialing application	1611
prior to the provider's employment. A contracting entity that	1612
does not complete the credentialing process within the ninety-day	1613
period specified in this division is liable for either a civil	1614
penalty payable to the provider in the amount of five hundred	1615
dollars per day, including weekend days, starting at the	1616
expiration of that ninety-day period until the provider's	1617
credentialing application is granted or denied or retroactive	1618
reimbursement to the provider according to the terms of the	1619
contract for any basic health care services, specialty health care	1620
services, or supplemental health care services the provider	1621
provided to enrollees starting at the expiration of that	1622
ninety-day period until the provider's credentialing application	1623
is granted or denied. When the credentialing process of the	1624
contracting entity exceeds the ninety-day period, the contracting	1625
entity shall select the liability to which the contracting entity	1626
is subject and shall inform the provider of the contracting	1627
entity's selection.	1628

(2) The credentialing process for a medicaid managed care	1629
plan starts when the provider submits a credentialing form and	1630
the provider's national provider number issued by the centers for	1631
medicare and medicaid services.	1632

(3) The requirement that the credentialing process be	1633
completed within the ninety-day period specified in division	1634
(C)(1) of this section does not apply to a contracting entity if a	1635
provider that submits a credentialing form to the contracting	1636
entity under that division is a hospital.	1637

(D) Any communication between the provider and the	1638
contracting entity shall be electronically, by facsimile, or by	1639
certified mail, return receipt requested.	1640

(E) If the state medical board or its agent has primary	1641
source verified the medical education, graduate medical education,	1642
and examination history of the physician, or the status of the	1643
physician with the educational commission for foreign medical	1644
graduates, if applicable, the contracting entity may accept the	1645
documentation of primary source verification from the state	1646
medical board's web site or from its agent and is not required to	1647
perform primary source verification of the medical education,	1648
graduate medical education, and examination history of the	1649
physician or the status of the physician with the educational	1650
commission for foreign medical graduates, if applicable, as a	1651
condition for initially credentialing or recredentialing the	1652
physician.	1653

Sec. 3963.07. (A) All remittance notices sent by a payer,	1654
whether written or electronic, shall include both of the	1655
following:	1656

(1) The name of the payer issuing the payment to the	1657
participating provider;	1658

(2) The name of the contracting entity through which the	1659
payment rate and any discount are claimed, if the contracting	1660
entity is different from the payer.	1661

(B) Division (A) of this section takes effect March 31, 2009.

1662

Sec. 3963.08.  The superintendent of insurance shall adopt	1663
any rules necessary for the implementation of this chapter.	1664

Sec. 3963.09. (A) A series of violations of this chapter by	1665
any person regulated by the department of insurance under Title	1666
XVII or Title XXXIX of the Revised Code that, taken together,	1667
constitute a pattern or practice of violating this chapter may be	1668
defined as an unfair and deceptive insurance practice under	1669
sections 3901.19 to 3901.26 of the Revised Code.	1670

(B) The superintendent of insurance may conduct a market	1671
conduct examination of any person regulated by the department of	1672
insurance under Title XVII or Title XXXIX of the Revised Code to	1673
determine whether any violation of this chapter has occurred. When	1674
conducting that type of examination, the superintendent of	1675
insurance may assess the costs of the examination against the	1676
person examined. The superintendent may enter into a consent	1677
agreement to impose any administrative assessment or fine for	1678
conduct discovered that may be a violation of this chapter. All	1679
costs, assessments, and fines collected under this section shall	1680
be deposited to the credit of the department of insurance	1681
operating fund.	1682

Sec. 3963.10.  This chapter does not apply with respect to	1683
any of the following:	1684

(A) A contract or provider agreement between a provider and	1685
the state or federal government, a state agency, or federal	1686
agency for health care services provided through a program for	1687
medicaid or medicare;	1688

(B) A contract for payments made to providers for rendering	1689
health care services to claimants pursuant to claims made under	1690
Chapter 4121., 4123., 4127., or 4131. of the Revised Code;	1691

(C) An exclusive contract between a health insuring	1692
corporation and a single group of providers in a specific	1693
geographic area to provide or arrange for the provision of health	1694
care services.	1695

Sec. 3963.11. (A) No contracting entity shall do any of the	1696
following:	1697

(1) Offer to a provider other than a hospital a health care	1698
contract that includes a most favored nation clause;	1699

(2) Enter into a health care contract with a provider other	1700
than a hospital that includes a most favored nation clause;	1701

(3) Amend an existing health care contract previously entered	1702
into with a provider other than a hospital to include a most	1703
favored nation clause.	1704

(B) This section shall not go into effect until three years	1705
after the effective date of this section.	1706

(C) As used in this section:

1707

(1) "Contracting entity," "health care contract," "health	1708
care services," "participating provider," and "provider" have the	1709
same meanings as in section 3963.01 of the Revised Code.	1710

(2) "Most favored nation clause" means a provision in a	1711
health care contract that does any of the following:	1712

(a) Prohibits, or grants a contracting entity an option to	1713
prohibit, the participating provider from contracting with another	1714
contracting entity to provide health care services at a lower	1715
price than the payment specified in the contract;	1716

(b) Requires, or grants a contracting entity an option to	1717
require, the participating provider to accept a lower payment in	1718
the event the participating provider agrees to provide health care	1719
services to any other contracting entity at a lower price;	1720

(c) Requires, or grants a contracting entity an option to	1721
require, termination or renegotiation of the existing health care	1722
contract in the event the participating provider agrees to provide	1723
health care services to any other contracting entity at a lower	1724
price;	1725

(d) Requires the participating provider to disclose the	1726
participating provider's contractual reimbursement rates with	1727
other contracting entities.	1728

Sec. 5111.17.  (A) The department of job and family services	1729
may enter into contracts with managed care organizations,	1730
including health insuring corporations, under which the	1731
organizations are authorized to provide, or arrange for the	1732
provision of, health care services to medical assistance	1733
recipients who are required or permitted to obtain health care	1734
services through managed care organizations as part of the care	1735
management system established under section 5111.16 of the	1736
Revised Code.	1737

(B) The director of job and family services may adopt rules	1738
in accordance with Chapter 119. of the Revised Code to implement	1739
this section.	1740

(C) The department of job and family services shall allow	1741
managed care plans to use providers to render care upon	1742
completion of the managed care plan's credentialing process.	1743

Section 2. That existing sections 1751.13, 1753.01, 1753.07,	1744
1753.09, 2317.54, 3701.741, 3702.51, and 5111.17 and sections	1745
1753.03, 1753.04, 1753.05, and 1753.08 of the Revised Code are	1746
hereby repealed.	1747

Section 3. Sections 3963.01 to 3963.11 of the Revised Code,	1748
as enacted by this act, shall apply only to contracts that are	1749
delivered, issued for delivery, or renewed or materially amended	1750
in this state on or after the effective date of this act. A	1751
health insuring corporation having fewer than fifteen thousand	1752
enrollees shall comply with the provisions of this section within	1753
twelve months after the effective date of this act.	1754

Section 4. Section 3963.06 of the Revised Code, as enacted	1755
by this act, takes effect ninety days after the effective date of	1756
this act.	1757

Section 5. (A) As used in this section and Section 6 of this	1758
act:	1759

(1) "Most favored nation clause" means a provision in a	1760
health care contract that does any of the following:	1761

(a) Prohibits, or grants a contracting entity an option to	1762
prohibit, the participating provider from contracting with another	1763
contracting entity to provide health care services at a lower	1764
price than the payment specified in the contract;	1765

(b) Requires, or grants a contracting entity an option to	1766
require, the participating provider to accept a lower payment in	1767
the event the participating provider agrees to provide health care	1768
services to any other contracting entity at a lower price;	1769

(c) Requires, or grants a contracting entity an option to	1770
require, termination or renegotiation of the existing health care	1771
contract in the event the participating provider agrees to provide	1772
health care services to any other contracting entity at a lower	1773
price;	1774

(d) Requires the participating provider to disclose the	1775
participating provider's contractual reimbursement rates with	1776
other contracting entities.	1777

(2) "Contracting entity," "health care contract," "health	1778
care services," "participating provider," and "provider" have the	1779
same meanings as in section 3963.01 of the Revised Code, as	1780
enacted by this act.	1781

(B) No health care contract that includes a most favored	1782
nation clause shall be entered into, and no health care contract	1783
at the instance of a contracting entity shall be amended or	1784
renewed to include a most favored nation clause, for a period of	1785
two years after the effective date of this act, subject to	1786
extension as provided in Section 6 of this act. This section does	1787
not apply to and does not prohibit the continued use of a most	1788
favored nation clause in a health care contract that is between a	1789
contracting entity and a hospital and that is in existence on the	1790
effective date of this act even if the health care contract is	1791
materially amended with respect to any provision of the health	1792
care contract other than the most favored nation clause during	1793
the two-year period specified in this section or during any	1794
extended period of time as provided in Section 6 of this act.	1795

Section 6. (A) There is hereby created the Joint Legislative	1796
Study Commission on Most Favored Nation Clauses in Health Care	1797
Contracts consisting of seventeen members as follows:	1798

(1) The Superintendent of Insurance;

1799

(2) Two members of the House of Representatives, one	1800
representing the majority party and one representing the minority	1801
party;	1802

(3) Two members of the Senate, one representing the majority	1803
party and one representing the minority party;	1804

(4) Three providers who are individuals;

1805

(5) Two representatives of hospitals;

1806

(6) Two representatives of contracting entities regulated by	1807
the Department of Insurance under Title XVII of the Revised Code;	1808

(7) Two representatives of contracting entities regulated by	1809
the Department of Insurance under Title XXXIX of the Revised Code;	1810

(8) One representative of an employer that pays for the	1811
health insurance coverage of its employees;	1812

(9) A licensed attorney with an expertise in antitrust law	1813
who represents providers;	1814

(10) A licensed attorney with an expertise in antitrust law	1815
who represents contracting entities that have used most favored	1816
nation clauses in their health care contracts and that are	1817
regulated by the Department of Insurance under either Title XVII	1818
or Title XXXIX of the Revised Code.	1819

(B) The members of the Commission shall be appointed as	1820
follows:	1821

(1) The Speaker of the House of Representatives shall appoint	1822
the two members of the House specified in division (A)(2) of this	1823
section.	1824

(2) The President of the Senate shall appoint the two members	1825
of the Senate specified in division (A)(3) of this section.	1826

(3) The Speaker of the House of Representatives and the	1827
President of the Senate jointly shall appoint the remaining	1828
members specified in divisions (A)(4) to (10) of this section.	1829

(C) Initial appointments to the Commission shall be made	1830
within thirty days after the effective date of this act. The	1831
appointments shall be for the term of the Commission as provided	1832
in division (F)(2) of this section. Vacancies shall be filled in	1833
the same manner provided for original appointments.	1834

(D)(1) The Superintendent of Insurance shall be the	1835
Chairperson of the Commission. Meetings of the Commission shall be	1836
at the call of the Chairperson. All of the members of the	1837
Commission shall be voting members. Meetings of the Commission	1838
shall be held pursuant to section 121.22 of the Revised Code.	1839

(2) The Department of Insurance shall provide office space or	1840
other facilities, any administrative or other technical,	1841
professional, or clerical employees, and any necessary supplies	1842
for the work of the Commission.	1843

(3) The Chairperson of the Commission shall keep the records	1844
of the Commission. Upon submission of the Commission's final	1845
report to the General Assembly under division (F) of this section,	1846
the Chairperson shall deliver all of the Commission's records to	1847
the General Assembly.	1848

(E)(1) The Commission shall study the following areas	1849
pertaining to health care contracts:	1850

(a) The procompetitive and anticompetitive aspects of most	1851
favored nation clauses;	1852

(b) The impact of most favored nation clauses on health care	1853
costs and on the availability of and accessibility to quality	1854
health care;	1855

(c) The costs associated with the enforcement of most favored	1856
nation clauses;	1857

(d) Other state laws and rules pertaining to most favored	1858
nation clauses in their health care contracts;	1859

(e) Matters determined by the Department of Insurance as	1860
relevant to the study of most favored nation clauses;	1861

(f) Any other matters that the Commission considers	1862
appropriate to determine the effectiveness of most favored nation	1863
clauses.	1864

(2) The Commission may take testimony from experts or	1865
interested parties on the areas of its study as described in	1866
division (E)(1) of this section.	1867

(F)(1) Not less than ninety days prior to the expiration of	1868
the two-year period specified in Section 5 of this act, the	1869
Commission shall report its preliminary findings to the General	1870
Assembly and a recommendation of whether to extend that two-year	1871
period for one additional year. If the General Assembly does not	1872
grant the extension, the Commission shall submit its final report	1873
to the General Assembly not later than three months after the	1874
expiration of the two-year period specified in Section 5 of this	1875
act. If the General Assembly grants the extension, the extension	1876
shall be for not more than one year after the expiration of the	1877
two-year period specified in Section 5 of this act, and the	1878
Commission shall submit its final report to the General Assembly	1879
not later than six months prior to the expiration of the one-year	1880
extension.	1881

(2) The final report of the Commission shall include its	1882
findings and recommendations on whether state law should prohibit	1883
or restrict most favored nation clauses in health care contracts.	1884
The Commission shall cease to exist upon the submission of its	1885
final report to the General Assembly.	1886

Section 7. (A) There is hereby created the Advisory Committee	1887
on Eligibility and Real Time Claim Adjudication to study and	1888
recommend mechanisms or standards that will enable providers to	1889
send to and receive from payers sufficient information to enable a	1890
provider to determine at the time of the enrollee's visit the	1891
enrollee's eligibility for services covered by the payer as well	1892
as real time adjudication of provider claims for services.	1893

(B) The Superintendent of Insurance or the Superintendent's	1894
designee shall be a member of the Advisory Committee and shall	1895
appoint at least one representative from each of the following	1896
groups or entities:	1897

(1) Persons eligible for health care benefits under a health	1898
benefit plan;	1899

(2) Physicians;

1900

(3) Hospitals;

1901

(4) Health benefit plan issuers;

1902

(5) Other health care providers;

1903

(6) Health care administrators;

1904

(7) Payers of health care benefits, including employers;

1905

(8) Preferred provider networks;

1906

(9) Health care technology vendors;

1907

(10) The Office of Information Technology.

1908

(C) Initial appointments to the Advisory Committee shall be	1909
made within thirty days after the effective date of this act. The	1910
appointments shall be for the term of the Advisory Committee as	1911
provided in division (I) of this section. Vacancies shall be	1912
filled in the same manner provided for original appointments.	1913
Members of the Advisory Committee shall serve without	1914
compensation.	1915

(D)(1) The Superintendent of Insurance shall be the	1916
Chairperson of the Advisory Committee. Meetings of the Advisory	1917
Committee shall be at the call of the Chairperson. All of the	1918
members of the Advisory Committee shall be voting members.	1919
Meetings of the Advisory Committee shall be held pursuant to	1920
section 121.22 of the Revised Code.	1921

(2) The Department of Insurance shall provide office space or	1922
other facilities, any administrative or other technical,	1923
professional, or clerical employees, and any necessary supplies	1924
for the work of the Advisory Committee.	1925

(E)(1) The Advisory Committee shall advise the Superintendent	1926
of Insurance on both of the following:	1927

(a) The technical aspects of using the transaction standards	1928
mandated by the "Health Insurance Portability and Accountability	1929
Act of 1996," 110 Stat. 1955, 42 U.S.C. 1320d, et seq., and the	1930
transaction standards and rules of the Council for Affordable	1931
Quality Healthcare Committee on Operating Rules for Information	1932
Exchange to require health benefit plan issuers and administrators	1933
to provide access to information technology that will enable	1934
physicians and other health care providers to generate a request	1935
for eligibility information at the point of service that is	1936
compliant with those transaction standards;	1937

(b) The data elements that health benefit plan issuers and	1938
administrators are required to make available, using, to the	1939
extent possible, the framework adopted by the Council for	1940
Affordable Quality Healthcare Committee on Operating Rules for	1941
Information Exchange.	1942

(2) The Advisory Committee shall consider including the	1943
following data elements in the information that must be made	1944
available in eligibility and real time adjudication transactions:	1945

(a) The name, date of birth, member identification number,	1946
and coverage status of the patient;	1947

(b) The identification of the payer, insurer, issuer, and	1948
administrator, as applicable;	1949

(c) The name and telephone number of the payer's contact	1950
person;	1951

(d) The payer's address;

1952

(e) The name and address of the subscriber;

1953

(f) The patient's relationship to the subscriber;

1954

(g) The type of service;

1955

(h) The type of health benefit plan or product;

1956

(i) The effective date of the health care coverage;

1957

(j) For professional services:

1958

(i) The amount of any copayment;

1959

(ii) The amount of an individual deductible;

1960

(iii) The amount of a family deductible;

1961

(iv) Benefit limitations and maximums.

1962

(k) For facility services:

1963

(i) The amount of any copayment or coinsurance;

1964

(ii) The amount of an individual deductible;

1965

(iii) The amount of a family deductible;

1966

(iv) Benefit limitations and maximums.

1967

(l) Precertification or prior authorization requirements;

1968

(m) Policy maximum limits;

1969

(n) Patient liability for a proposed service;

1970

(o) The health benefit plan coverage amount for a proposed	1971
service.	1972

(F) The Advisory Committee shall make recommendations	1973
regarding all of the following:	1974

(1) The use of internet web site technologies, smart card	1975
technologies, magnetic strip technologies, biometric technologies,	1976
or other information technologies to facilitate the generation of	1977
a request for eligibility information that is compliant with the	1978
transaction standards and rules of the Council for Affordable	1979
Quality Healthcare Committee on Operating Rules for Information	1980
Exchange;	1981

(2) Time frames for the implementation of the recommendations	1982
in division (F)(1) of this section;	1983

(3) When a provider may rely upon the eligibility information	1984
transmitted by a payer regarding a service provided to an enrollee	1985
for purposes of allocating responsibility for payment for services	1986
rendered by the provider. The Advisory Committee shall further	1987
recommend how disputes over enrollee eligibility for services	1988
received shall be resolved taking into consideration the legal	1989
relationship between the provider, the enrollee, and the payer.	1990

(G) The recommendations made by the Advisory Committee shall	1991
not endorse or otherwise limit the choice of products or services	1992
available to health care payers, purchasers, or providers.	1993

(H) Not later than January 1, 2009, the Advisory Committee	1994
shall provide the General Assembly with a report of its findings	1995
and recommendations for legislative action to standardize	1996
eligibility and real time adjudication transactions between	1997
providers and payers. The transaction standards adopted by the	1998
General Assembly shall, at a minimum, comply with the standards	1999
mandated by the "Health Insurance Portability and Accountability	2000
Act of 1996," 110 Stat. 1955, 42 U.S.C. 1320d, et seq., as further	2001
defined in Title 45, part 162 of the Code of Federal Regulations	2002
to the extent that the "Health Insurance Portability and	2003
Accountability Act of 1996" applies to the transaction.	2004

(I) The Advisory Committee shall cease to exist upon the	2005
submission of its report and recommendations to the General	2006
Assembly.	2007