As Reported by the Senate Insurance, Commerce and Labor Committee

129th General Assembly Regular Session 2011-2012

Sub. H. B. No. 218

Representative Hottinger 

Cosponsors: Representatives Grossman, Stebelton, Carey, Blair, Buchy, Blessing, Ruhl, Maag, Letson, Hackett, Carney, Luckie, Schuring, Sears, Adams, R., Anielski, Antonio, Boose, Budish, Combs, Derickson, Dovilla, Fedor, Fende, Foley, Gardner, Garland, Gerberry, Goyal, Hagan, C., Hagan, R., Hall, Heard, Johnson, Kozlowski, Lundy, Mallory, McKenney, Milkovich, Murray, Newbold, O'Brien, Okey, Peterson, Pillich, Ramos, Slaby, Uecker, Weddington, Young, Yuko Speaker Batchelder 

Senators Beagle, Bacon 

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A BILL

To amend sections 1751.11, 1751.33, 1751.35, 1751.66,

1

1751.77, 1751.78, 1751.811, 1751.83, 1751.87,

2

1751.89, 3901.045, 3923.60, and 4731.36; to enact

3

sections 3922.01 to 3922.23; and to repeal

4

sections 1751.831, 1751.84, 1751.85, 1751.88,

5

3901.80, 3901.81, 3901.82, 3901.83, 3901.84,

6

3923.66, 3923.67, 3923.68, 3923.681, 3923.69,

7

3923.70, 3923.75, 3923.76, 3923.77, 3923.78, and

8

3923.79 of the Revised Code to use the compendia

9

adopted by the United States Department of Health

10

and Human Services to determine whether an insurer

11

may exclude coverage for off-label drug usage and

12

to revise the external review process used by

13

health plan issuers.

14

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

Section 1. That sections 1751.11, 1751.33, 1751.35, 1751.66,	15
1751.77, 1751.78, 1751.811, 1751.83, 1751.87, 1751.89, 3901.045,	16
3923.60, and 4731.36 be amended and sections 3922.01, 3922.02,	17
3922.03, 3922.04, 3922.05, 3922.06, 3922.07, 3922.08, 3922.09,	18
3922.10, 3922.11, 3922.12, 3922.13, 3922.14, 3922.15, 3922.16,	19
3922.17, 3922.18, 3922.19, 3922.20, 3922.21, 3922.22, and 3922.23	20
of the Revised Code be enacted to read as follows:	21

Sec. 1751.11.  (A) Every subscriber of a health insuring	22
corporation is entitled to an evidence of coverage for the health	23
care plan under which health care benefits are provided.	24

(B) Every subscriber of a health insuring corporation that	25
offers basic health care services is entitled to an identification	26
card or similar document that specifies the health insuring	27
corporation's name as stated in its articles of incorporation, and	28
any trade or fictitious names used by the health insuring	29
corporation. The identification card or document shall list at	30
least one toll-free telephone number that provides the subscriber	31
with access, to information on a twenty-four-hours-per-day,	32
seven-days-per-week basis, as to how health care services may be	33
obtained. The identification card or document shall also list at	34
least one toll-free number that, during normal business hours,	35
provides the subscriber with access to information on the coverage	36
available under the subscriber's health care plan and information	37
on the health care plan's internal and external review processes.	38

(C) No evidence of coverage, or amendment to the evidence of	39
coverage, shall be delivered, issued for delivery, renewed, or	40
used, until the form of the evidence of coverage or amendment has	41
been filed by the health insuring corporation with the	42
superintendent of insurance. If the superintendent does not	43
disapprove the evidence of coverage or amendment within sixty days	44
after it is filed it shall be deemed approved, unless the	45
superintendent sooner gives approval for the evidence of coverage	46
or amendment. With respect to an amendment to an approved evidence	47
of coverage, the superintendent only may disapprove provisions	48
amended or added to the evidence of coverage. If the	49
superintendent determines within the sixty-day period that any	50
evidence of coverage or amendment fails to meet the requirements	51
of this section, the superintendent shall so notify the health	52
insuring corporation and it shall be unlawful for the health	53
insuring corporation to use such evidence of coverage or	54
amendment. At any time, the superintendent, upon at least thirty	55
days' written notice to a health insuring corporation, may	56
withdraw an approval, deemed or actual, of any evidence of	57
coverage or amendment on any of the grounds stated in this	58
section. Such disapproval shall be effected by a written order,	59
which shall state the grounds for disapproval and shall be issued	60
in accordance with Chapter 119. of the Revised Code.	61

(D) No evidence of coverage or amendment shall be delivered,	62
issued for delivery, renewed, or used:	63

(1) If it contains provisions or statements that are	64
inequitable, untrue, misleading, or deceptive;	65

(2) Unless it contains a clear, concise, and complete	66
statement of the following:	67

(a) The health care services and insurance or other benefits,	68
if any, to which an enrollee is entitled under the health care	69
plan;	70

(b) Any exclusions or limitations on the health care	71
services, type of health care services, benefits, or type of	72
benefits to be provided, including copayments and deductibles;	73

(c) An enrollee's personal financial obligation for	74
noncovered services;	75

(d) Where and in what manner general information and	76
information as to how health care services may be obtained is	77
available, including a toll-free telephone number;	78

(e) The premium rate with respect to individual and	79
conversion contracts, and relevant copayment and deductible	80
provisions with respect to all contracts. The statement of the	81
premium rate, however, may be contained in a separate insert.	82

(f) The method utilized by the health insuring corporation	83
for resolving enrollee complaints;	84

(g) The utilization review, internal review, and external	85
review procedures established under sections 1751.77 to 1751.85	86
1751.83 and Chapter 3922. of the Revised Code.	87

(3) Unless it provides for the continuation of an enrollee's	88
coverage, in the event that the enrollee's coverage under the	89
group policy, contract, certificate, or agreement terminates while	90
the enrollee is receiving inpatient care in a hospital. This	91
continuation of coverage shall terminate at the earliest	92
occurrence of any of the following:	93

(a) The enrollee's discharge from the hospital;

94

(b) The determination by the enrollee's attending physician	95
that inpatient care is no longer medically indicated for the	96
enrollee; however, nothing in division (D)(3)(b) of this section	97
precludes a health insuring corporation from engaging in	98
utilization review as described in the evidence of coverage.	99

(c) The enrollee's reaching the limit for contractual	100
benefits;	101

(d) The effective date of any new coverage.

102

(4) Unless it contains a provision that states, in substance,	103
that the health insuring corporation is not a member of any	104
guaranty fund, and that in the event of the health insuring	105
corporation's insolvency, an enrollee is protected only to the	106
extent that the hold harmless provision required by section	107
1751.13 of the Revised Code applies to the health care services	108
rendered;	109

(5) Unless it contains a provision that states, in substance,	110
that in the event of the insolvency of the health insuring	111
corporation, an enrollee may be financially responsible for health	112
care services rendered by a provider or health care facility that	113
is not under contract to the health insuring corporation, whether	114
or not the health insuring corporation authorized the use of the	115
provider or health care facility.	116

(E) Notwithstanding divisions (C) and (D) of this section, a	117
health insuring corporation may use an evidence of coverage that	118
provides for the coverage of beneficiaries enrolled in medicare	119
pursuant to a medicare contract, or an evidence of coverage that	120
provides for the coverage of beneficiaries enrolled in the federal	121
employees health benefits program pursuant to 5 U.S.C.A. 8905, or	122
an evidence of coverage that provides for the coverage of medicaid	123
recipients, or an evidence of coverage that provides for the	124
coverage of beneficiaries under any other federal health care	125
program regulated by a federal regulatory body, or an evidence of	126
coverage that provides for the coverage of beneficiaries under any	127
contract covering officers or employees of the state that has been	128
entered into by the department of administrative services, if both	129
of the following apply:	130

(1) The evidence of coverage has been approved by the United	131
States department of health and human services, the United States	132
office of personnel management, the Ohio department of job and	133
family services, or the department of administrative services.	134

(2) The evidence of coverage is filed with the superintendent	135
of insurance prior to use and is accompanied by documentation of	136
approval from the United States department of health and human	137
services, the United States office of personnel management, the	138
Ohio department of job and family services, or the department of	139
administrative services.	140

Sec. 1751.33.  (A) Each health insuring corporation shall	141
provide to its subscribers a description of the health insuring	142
corporation, its method of operation, its service area, its most	143
recent provider list, its complaint procedure established pursuant	144
to section 1751.19 of the Revised Code, and a description of its	145
utilization review, internal review, and external review processes	146
established under sections 1751.77 to 1751.851751.83 and Chapter	147
3922. of the Revised Code. A health insuring corporation may	148
satisfy this requirement by delivering to its subscribers a	149
document that identifies a web site where the subscriber may view	150
this information. At the request of the subscriber, a health	151
insuring corporation shall provide this information in hard copy	152
by mail. A health insuring corporation providing basic health care	153
services or supplemental health care services shall provide this	154
information annually. A health insuring corporation providing only	155
specialty health care services shall provide this information	156
biennially.	157

(B) Each health insuring corporation, upon the request of a	158
subscriber, shall make available its most recent statutory	159
financial statement.	160

Sec. 1751.35.  (A) The superintendent of insurance may	161
suspend or revoke any certificate of authority issued to a health	162
insuring corporation under this chapter if the superintendent	163
finds that:	164

(1) The health insuring corporation is operating in	165
contravention of its articles of incorporation, its health care	166
plan or plans, or in a manner contrary to that described in and	167
reasonably inferred from any other information submitted under	168
section 1751.03 of the Revised Code, unless amendments to such	169
submissions have been filed and have taken effect in compliance	170
with this chapter.	171

(2) The health insuring corporation fails to issue evidences	172
of coverage in compliance with the requirements of section 1751.11	173
of the Revised Code.	174

(3) The contractual periodic prepayments or premium rates	175
used do not comply with the requirements of section 1751.12 of the	176
Revised Code.	177

(4) The health insuring corporation enters into a contract,	178
agreement, or other arrangement with any health care facility or	179
provider, that does not comply with the requirements of section	180
1751.13 of the Revised Code, or the corporation fails to provide	181
an annual certificate as required by section 1751.13 of the	182
Revised Code.	183

(5) The superintendent determines, after a hearing conducted	184
in accordance with Chapter 119. of the Revised Code, that the	185
health insuring corporation no longer meets the requirements of	186
section 1751.04 of the Revised Code.	187

(6) The health insuring corporation is no longer financially	188
responsible and may reasonably be expected to be unable to meet	189
its obligations to enrollees or prospective enrollees.	190

(7) The health insuring corporation has failed to implement	191
the complaint system that complies with the requirements of	192
section 1751.19 of the Revised Code.	193

(8) The health insuring corporation, or any agent or	194
representative of the corporation, has advertised, merchandised,	195
or solicited on its behalf in contravention of the requirements of	196
section 1751.31 of the Revised Code.	197

(9) The health insuring corporation has unlawfully	198
discriminated against any enrollee or prospective enrollee with	199
respect to enrollment, disenrollment, or price or quality of	200
health care services.	201

(10) The continued operation of the health insuring	202
corporation would be hazardous or otherwise detrimental to its	203
enrollees.	204

(11) The health insuring corporation has submitted false	205
information in any filing or submission required under this	206
chapter or any rule adopted under this chapter.	207

(12) The health insuring corporation has otherwise failed to	208
substantially comply with this chapter or any rule adopted under	209
this chapter.	210

(13) The health insuring corporation is not operating a	211
health care plan.	212

(14) The health insuring corporation has failed to comply	213
with any of the requirements of sections 1751.77 to 1751.88	214
1751.87 or Chapter 3922. of the Revised Code.	215

(B) A certificate of authority shall be suspended or revoked	216
only after compliance with the requirements of Chapter 119. of the	217
Revised Code.	218

(C) When the certificate of authority of a health insuring	219
corporation is suspended, the health insuring corporation, during	220
the period of suspension, shall not enroll any additional	221
subscribers or enrollees except newborn children or other newly	222
acquired dependents of existing subscribers or enrollees, and	223
shall not engage in any advertising or solicitation whatsoever.	224

(D) When the certificate of authority of a health insuring	225
corporation is revoked, the health insuring corporation, following	226
the effective date of the order of revocation, shall conduct no	227
further business except as may be essential to the orderly	228
conclusion of the affairs of the health insuring corporation. The	229
health insuring corporation shall engage in no further advertising	230
or solicitation whatsoever. The superintendent, by written order,	231
may permit such further operation of the health insuring	232
corporation as the superintendent may find to be in the best	233
interest of enrollees, to the end that enrollees will be afforded	234
the greatest practical opportunity to obtain continuing health	235
care coverage.	236

Sec. 1751.66.  (A) No individual or group health insuring	237
corporation policy, contract, or agreement that provides coverage	238
for prescription drugs shall limit or exclude coverage for any	239
drug approved by the United States food and drug administration on	240
the basis that the drug has not been approved by the United States	241
food and drug administration for the treatment of the particular	242
indication for which the drug has been prescribed, provided the	243
drug has been recognized as safe and effective for treatment of	244
that indication in one or more of the standard medical reference	245
compendia specified in division (B)(1) of this sectionadopted by	246
the United States department of health and human services under 42	247
U.S.C. 1395x(t)(2), as amended, or in medical literature that	248
meets the criteria specified in division (B)(2) of this section.	249

(B)(1) The compendia accepted for purposes of division (A) of	250
this section are the following:	251

(a) The "AMA drug evaluations," a publication of the American	252
medical association;	253

(b) The "AHFS (American hospital formulary service) drug	254
information," a publication of the American society of health	255
system pharmacists;	256

(c) "Drug information for the health care provider," a	257
publication of the United States pharmacopoeia convention.	258

(2) Medical literature may be accepted for purposes of	259
division (A) of this section only if all of the following apply:	260

(a)(1) Two articles from major peer-reviewed professional	261
medical journals have recognized, based on scientific or medical	262
criteria, the drug's safety and effectiveness for treatment of the	263
indication for which it has been prescribed;	264

(b)(2) No article from a major peer-reviewed professional	265
medical journal has concluded, based on scientific or medical	266
criteria, that the drug is unsafe or ineffective or that the	267
drug's safety and effectiveness cannot be determined for the	268
treatment of the indication for which it has been prescribed;	269

(c)(3) Each article meets the uniform requirements for	270
manuscripts submitted to biomedical journals established by the	271
international committee of medical journal editors or is published	272
in a journal specified by the United States department of health	273
and human services pursuant to Section 1861(t)(2)(B) of the	274
"Social Security Act," 107 Stat. 591 (1993), 42 U.S.C. 1395	275
(x)(t)(2)(B), as amended, as accepted peer-reviewed medical	276
literature.	277

(C) Coverage of a drug required by division (A) of this	278
section includes medically necessary services associated with the	279
administration of the drug.	280

(D) Division (A) of this section shall not be construed to do	281
any of the following:	282

(1) Require coverage for any drug if the United States food	283
and drug administration has determined its use to be	284
contraindicated for the treatment of the particular indication for	285
which the drug has been prescribed;	286

(2) Require coverage for experimental drugs not approved for	287
any indication by the United States food and drug administration;	288

(3) Alter any law with regard to provisions limiting the	289
coverage of drugs that have not been approved by the United States	290
food and drug administration;	291

(4) Require reimbursement or coverage for any drug not	292
included in the drug formulary or list of covered drugs specified	293
in a health insuring corporation contract;	294

(5) Prohibit a health insuring corporation from limiting or	295
excluding coverage of a drug, provided that the decision to limit	296
or exclude coverage of the drug is not based primarily on the	297
coverage of drugs required by this section.	298

(E) This section applies only to health insuring corporation	299
policies, contracts, and agreements that are described in division	300
(A) of this section and that are delivered, issued for delivery,	301
or renewed in this state on or after July 1, 1997.	302

Sec. 1751.77.  As used in sections 1751.77 to 1751.881751.87	303
of the Revised Code, unless otherwise specifically provided or as	304
otherwise required pursuant to applicable federal law or	305
regulations:	306

(A) "Adverse determination" means a determination by a health	307
insuring corporation or its designee utilization review	308
organization that an admission, availability of care, continued	309
stay, or other health care service has been reviewed and, based	310
upon the information provided, the health care service does not	311
meet the requirements for benefit payment under the health	312
insuring corporation's policy, contract, or agreement, and	313
coverage is therefore denied, reduced, or terminated.	314

(B) "Ambulatory review" means utilization review of health	315
care services performed or provided in an outpatient setting.	316

(C) "Authorized person" means a parent, guardian, or other	317
person authorized to act on behalf of an enrollee with respect to	318
health care decisions.	319

(D) "Case management" means a coordinated set of activities	320
conducted for individual patient management of serious,	321
complicated, protracted, or other specified health conditions.	322

(E) "Certification" means a determination by a health	323
insuring corporation or its designee utilization review	324
organization that an admission, availability of care, continued	325
stay, or other health care service has been reviewed and, based	326
upon the information provided, the health care service satisfies	327
the requirements for benefit payment under the health insuring	328
corporation's policy, contract, or agreement.	329

(F) "Clinical peer" means a physician when an evaluation is	330
to be made of the clinical appropriateness of health care services	331
provided by a physician. If an evaluation is to be made of the	332
clinical appropriateness of health care services provided by a	333
provider who is not a physician, "clinical peer" means either a	334
physician or a provider holding the same license as the provider	335
who provided the health care services.	336

(G) "Clinical review criteria" means the written screening	337
procedures, decision abstracts, clinical protocols, and practice	338
guidelines used by a health insuring corporation to determine the	339
necessity and appropriateness of health care services.	340

(H) "Concurrent review" means utilization review conducted	341
during a patient's hospital stay or course of treatment.	342

(I) "Discharge planning" means the formal process for	343
determining, prior to a patient's discharge from a health care	344
facility, the coordination and management of the care that the	345
patient is to receive following discharge from a health care	346
facility.	347

(J) "Participating provider" means a provider or health care	348
facility that, under a contract with a health insuring corporation	349
or with its contractor or subcontractor, has agreed to provide	350
health care services to enrollees with an expectation of receiving	351
payment, other than coinsurance, copayments, or deductibles,	352
directly or indirectly from the health insuring corporation.	353

(K) "Physician" means a provider who holds a certificate	354
issued under Chapter 4731. of the Revised Code authorizing the	355
practice of medicine and surgery or osteopathic medicine and	356
surgery or a comparable license or certificate from another state.	357

(L) "Prospective review" means utilization review that is	358
conducted prior to an admission or a course of treatment.	359

(M) "Retrospective review" means utilization review of	360
medical necessity that is conducted after health care services	361
have been provided to a patient. "Retrospective review" does not	362
include the review of a claim that is limited to an evaluation of	363
reimbursement levels, veracity of documentation, accuracy of	364
coding, or adjudication of payment.	365

(N) "Second opinion" means an opportunity or requirement to	366
obtain a clinical evaluation by a provider other than the provider	367
originally making a recommendation for proposed health care	368
services to assess the clinical necessity and appropriateness of	369
the proposed health care services.	370

(O) "Utilization review" means a process used to monitor the	371
use of, or evaluate the clinical necessity, appropriateness,	372
efficacy, or efficiency of, health care services, procedures, or	373
settings. Areas of review may include ambulatory review,	374
prospective review, second opinion, certification, concurrent	375
review, case management, discharge planning, or retrospective	376
review.	377

(P) "Utilization review organization" means an entity that	378
conducts utilization review, other than a health insuring	379
corporation performing a review of its own health care plans.	380

Sec. 1751.78.  (A)(1) Sections 1751.77 to 1751.881751.87 and	381
Chapter 3922. of the Revised Code apply to any health insuring	382
corporation that provides or performs utilization review services	383
in connection with its policies, contracts, and agreements	384
covering basic health care services and to any designee of the	385
health insuring corporation, or to any utilization review	386
organization that performs utilization review functions on behalf	387
of the health insuring corporation in connection with policies,	388
contracts, or agreements of the health insuring corporation	389
covering basic health care services.	390

(2) Nothing in sections 1751.77 to 1751.82 or section	391
1751.823 of the Revised Code shall be construed to require a	392
health insuring corporation to provide or perform utilization	393
review services in connection with health care services provided	394
under a policy, plan, or agreement of supplemental health care	395
services or specialty health care services.	396

(B)(1) Each health insuring corporation shall be responsible	397
for monitoring all utilization review and internal review	398
activities carried out by, or on behalf of, the health insuring	399
corporation and for ensuring that all requirements of sections	400
1751.77 to 1751.881751.87 and Chapter 3922. of the Revised Code,	401
and any rules adopted thereunder, are met. The health insuring	402
corporation shall also ensure that appropriate personnel have	403
operational responsibility for the conduct of the health insuring	404
corporation's utilization review program.	405

(2) If a health insuring corporation contracts to have a	406
utilization review organization or other entity perform the	407
utilization review functions required by sections 1751.77 to	408
1751.881751.87 and Chapter 3922. of the Revised Code, and any	409
rules adopted thereunder, the superintendent of insurance shall	410
hold the health insuring corporation responsible for monitoring	411
the activities of the utilization review organization or other	412
entity and for ensuring that the requirements of those sections	413
and rules are met.	414

Sec. 1751.811.  In lieu of conducting a prospective,	415
concurrent, or retrospective review under section 1751.81 of the	416
Revised Code, providing a reconsideration under section 1751.82 of	417
the Revised Code, or conducting an internal review under section	418
1751.83 of the Revised Code, a health insuring corporation may	419
afford an enrollee an opportunity for an external review under	420
section 1751.843922.08 or 1751.853922.10 of the Revised Code. If	421
an external review is conducted pursuant to this section, the	422
health insuring corporation is not required to afford the enrollee	423
an opportunity for any of the reviews that were disregarded	424
pursuant to this section, including the external review that may	425
have resulted from a review that was disregarded pursuant to this	426
section, unless new clinical information is submitted to the	427
health insuring corporation.	428

Sec. 1751.83.  A health insuring corporation shall establish	429
and maintain an internal review system that has been approved by	430
the superintendent of insurance. The system shall provide for	431
review by a clinical peer and include adequate and reasonable	432
procedures for review and resolution of appeals from enrollees	433
concerning adverse determinations made under section 1751.81 of	434
the Revised Code, including procedures for verifying and reviewing	435
appeals from enrollees whose medical conditions require expedited	436
review.	437

A health insuring corporation shall consider and provide a	438
written response to each request for an internal review not later	439
than sixtythirty days after receipt of the request, except that	440
if the seriousness of the enrollee's medical condition requires an	441
expedited review, the health insuring corporation shall provide	442
the written response not later than seven days after receipt of	443
the request or in accordance with applicable preemptive federal	444
laws or regulations. The response shall state the reason for the	445
health insuring corporation's decision, inform the enrollee of the	446
right to pursue a further review, and explain the procedures for	447
initiating the review, including the time frames within which the	448
enrollee must request the review, as specified in section 1751.84	449
or 1751.853922.02 of the Revised Code. Failure by a health	450
insuring corporation to provide a written response within the time	451
frames specified under this section shall be deemed a denial by	452
the health insuring corporation for purposes of requesting aan	453
external review under section 1751.831, 1751.84, or 1751.85	454
Chapter 3922. of the Revised Code.	455

If the health insuring corporation has denied, reduced, or	456
terminated coverage for a health care service on the grounds that	457
the service is not a service covered under the terms of the	458
enrollee's policy, contract, or agreement, the response shall	459
inform the enrollee of the right to request a review by the	460
superintendent of insurance under section 1751.831Chapter 3922.	461
of the Revised Code. If the health insuring corporation has	462
denied, reduced, or terminated coverage for a health care service	463
on the grounds that the service is not medically necessary, the	464
response shall inform the enrollee of the right to request an	465
external review under section 1751.84Chapter 3922. of the Revised	466
Code, except that if the enrollee meets the criteria set forth in	467
division (A) of section 1751.85 of the Revised Code, the response	468
shall inform the enrollee of the right to request an external	469
review under section 1751.85 of the Revised Code.	470

The health insuring corporation shall make available to the	471
superintendent for inspection copies of all documents in the	472
health insuring corporation's possession related to reviews	473
conducted pursuant to this section, including medical records	474
related to those reviews, and of responses, for three years	475
following completion of the review.	476

Sec. 1751.87.  Nothing in sections 1751.77 to 1751.851751.83	477
of the Revised Code shall be construed to create a cause of action	478
against any of the following:	479

(A) Anan employer that provides health care benefits to	480
employees through a health insuring corporation;	481

(B) A clinical peer, medical expert, or independent review	482
organization that participates in an external review under section	483
1751.84 or 1751.85 of the Revised Code;	484

(C) A health insuring corporation that provides coverage for	485
benefits in accordance with division (F) of section 1751.84 of	486
division (C)(11) of section 1751.85 of the Revised Code.	487

Sec. 1751.89.  Sections 1751.77 to 1751.851751.83 of the	488
Revised Code do not apply to either of the following:	489

(A) Coverage provided to beneficiaries enrolled in the	490
medicare+choice program operated under Title XVIII of the "Social	491
Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended;	492

(B) Coverage provided to medicaid recipients;

493

(C) Coverage provided to participants of the children's	494
buy-in program.	495

Sec. 3901.045. (A) The superintendent of insurance may	496
receive documents and information, including otherwise	497
confidential or privileged documents and information, from local,	498
state, federal, and international regulatory and law enforcement	499
agencies, from local, state, and federal prosecutors, and from the	500
national association of insurance commissioners and its affiliates	501
and subsidiaries, provided that the superintendent maintains as	502
confidential or privileged any document or information received	503
with notice or the understanding that the document or information	504
is confidential or privileged under the laws of the jurisdiction	505
that is the source of the document or information.	506

(B) The superintendent may also receive documents and	507
information, including otherwise confidential or privileged	508
documents and information, from the chief deputy rehabilitator,	509
the chief deputy liquidator, other deputy rehabilitators and	510
liquidators, and from any other person employed by, or acting on	511
behalf of, the superintendent pursuant to Chapter 3901. or 3903.	512
of the Revised Code, provided that the superintendent maintains as	513
confidential or privileged any document or information received	514
with the notice or understanding that the document or information	515
is confidential or privileged, except that the superintendent may	516
share and disclose such a document or information when authorized	517
by other sections of the Revised Code.	518

(C) The superintendent has the authority to maintain as	519
confidential or privileged the documents and information received	520
pursuant to this section.	521

(D) The superintendent's authority to receive documents and	522
information under this section, from the persons and subject to	523
the conditions listed in this section, is not limited in any way	524
by section 1751.19, 3901.36, 3901.44, 3901.48, 3901.70, 3901.83,	525
3903.11, 3903.72, 3903.88, 3905.492, 3905.50, 3922.21, or 3999.36	526
of the Revised Code.	527

Sec. 3922.01.  As used in this chapter:

528

(A) "Adverse benefit determination" means a decision by a	529
health plan issuer:	530

(1) To deny, reduce, or terminate a requested health care	531
service or payment in whole or in part, including all of the	532
following:	533

(a) A determination that the health care service does not	534
meet the health plan issuer's requirements for medical necessity,	535
appropriateness, health care setting, level of care, or	536
effectiveness, including experimental or investigational	537
treatments;	538

(b) A determination of an individual's eligibility for	539
individual health insurance coverage, including coverage offered	540
to individuals through a nonemployer group, to participate in a	541
plan or health insurance coverage;	542

(c) A determination that a health care service is not a	543
covered benefit;	544

(d) The imposition of an exclusion, including exclusions for	545
pre-existing conditions, source of injury, network, or any other	546
limitation on benefits that would otherwise be covered.	547

(2) Not to issue individual health insurance coverage to an	548
applicant, including coverage offered to individuals through a	549
nonemployer group;	550

(3) To rescind coverage on a health benefit plan.

551

(B) "Ambulatory review" has the same meaning as in section	552
1751.77 of the Revised Code.	553

(C) "Authorized representative" means an individual who	554
represents a covered person in an internal appeal or external	555
review process of an adverse benefit determination who is any of	556
the following:	557

(1) A person to whom a covered individual has given express,	558
written consent to represent that individual in an internal	559
appeals process or external review process of an adverse benefit	560
determination;	561

(2) A person authorized by law to provide substituted consent	562
for a covered individual;	563

(3) A family member or a treating health care professional,	564
but only when the covered person is unable to provide consent.	565

(D) "Best evidence" means evidence based on all of the	566
following sources, listed according to priority, as they are	567
available:	568

(1) Randomized clinical trials;

569

(2) Cohort studies or case-control studies;

570

(3) Case series;

571

(4) Expert opinion.

572

(E) "Covered person" means a policyholder, subscriber,	573
enrollee, member, or individual covered by a health benefit plan.	574
"Covered person" does include the covered person's authorized	575
representative with regard to an internal appeal or external	576
review in accordance with division (C) of this section. "Covered	577
person" does not include the covered person's representative in	578
any other context.	579

(F) "Covered benefits" or "benefits" means those health care	580
services to which a covered person is entitled under the terms of	581
a health benefit plan.	582

(G) "Emergency medical condition" has the same meaning as in	583
section 1753.28 of the Revised Code.	584

(H) "Emergency services" has the same meaning as in section	585
1753.28 of the Revised Code.	586

(I) "Evidence-based standard" means the conscientious,	587
explicit, and judicious use of the current best evidence, based on	588
a systematic review of the relevant research, in making decisions	589
about the care of individuals.	590

(J) "Facility" means an institution providing health care	591
services, or a health care setting, including hospitals and other	592
licensed inpatient centers, ambulatory, surgical, treatment,	593
skilled nursing, residential treatment, diagnostic, laboratory,	594
and imaging centers, and rehabilitation and other therapeutic	595
health settings.	596

(K) "Final adverse benefit determination" means an adverse	597
benefit determination that is upheld at the completion of a health	598
plan issuer's internal appeals process.	599

(L) "Health benefit plan" means a policy, contract,	600
certificate, or agreement offered by a health plan issuer to	601
provide, deliver, arrange for, pay for, or reimburse any of the	602
costs of health care services, including benefit plans marketed in	603
the individual or group market by all associations, whether bona	604
fide or non-bona fide. "Health benefit plan" also means a limited	605
benefit plan, except as follows. "Health benefit plan" does not	606
mean any of the following types of coverage: a policy, contract,	607
certificate, or agreement that covers only a specified accident,	608
accident only, credit, dental, disability income, long-term care,	609
hospital indemnity, medicare supplement, medicare, tricare,	610
specified disease, or vision care; coverage issued as a supplement	611
to liability insurance; insurance arising out of workers'	612
compensation or similar law; automobile medical payment insurance;	613
or insurance under which benefits are payable with or without	614
regard to fault and which is statutorily required to be contained	615
in any liability insurance policy or equivalent self-insurance; a	616
medicare supplement policy of insurance, as defined by the	617
superintendent of insurance by rule, coverage under a plan through	618
medicare, medicaid, or the federal employees benefit program; any	619
coverage issued under Chapter 55 of Title 10 of the United States	620
Code and any coverage issued as a supplement to that coverage.	621

(M) "Health care professional" means a physician,	622
psychologist, nurse practitioner, or other health care	623
practitioner licensed, accredited, or certified to perform health	624
care services consistent with state law.	625

(N) "Health care provider" or "provider" means a health care	626
professional or facility.	627

(O) "Health care services" means services for the diagnosis,	628
prevention, treatment, cure, or relief of a health condition,	629
illness, injury, or disease.	630

(P) "Health plan issuer" means an entity subject to the	631
insurance laws and rules of this state, or subject to the	632
jurisdiction of the superintendent of insurance, that contracts,	633
or offers to contract to provide, deliver, arrange for, pay for,	634
or reimburse any of the costs of health care services under a	635
health benefit plan, including a sickness and accident insurance	636
company, a health insuring corporation, a fraternal benefit	637
society, a self-funded multiple employer welfare arrangement, or a	638
nonfederal, government health plan. "Health plan issuer" includes	639
a third party administrator licensed under Chapter 3959. of the	640
Revised Code to the extent that the benefits that such an entity	641
is contracted to administer under a health benefit plan are	642
subject to the insurance laws and rules of this state or subject	643
to the jurisdiction of the superintendent.	644

(Q) "Health information" means information or data, whether	645
oral or recorded in any form or medium, and personal facts or	646
information about events or relationships that relates to all of	647
the following:	648

(1) The past, present, or future physical, mental, or	649
behavioral health or condition of a covered person or a member of	650
the covered person's family;	651

(2) The provision of health care services or health-related	652
benefits to a covered person;	653

(3) Payment for the provision of health care services to or	654
for a covered person.	655

(R) "Independent review organization" means an entity that is	656
accredited by a nationally recognized private accrediting	657
organization to conduct independent external reviews of adverse	658
benefit determinations and is accredited pursuant to section	659
3922.13 of the Revised Code.	660

(S) "Medical or scientific evidence" means evidence found in	661
any of the following sources:	662

(1) Peer-reviewed scientific studies published in, or	663
accepted for publication by, medical journals that meet nationally	664
recognized requirements for scientific manuscripts and that submit	665
most of their published articles for review by experts who are not	666
part of the editorial staff;	667

(2) Peer-reviewed medical literature, including literature	668
relating to therapies reviewed and approved by a qualified	669
institutional review board, biomedical compendia and other medical	670
literature that meet the criteria of the national institutes of	671
health's library of medicine for indexing in index medicus and	672
elsevier science ltd. for indexing in excerpta medicus;	673

(3) Medical journals recognized by the secretary of health	674
and human services under section 1861(t)(2) of the federal social	675
security act;	676

(4) The following standard reference compendia:

677

(a) The American hospital formulary service drug information;

678

(b) Drug facts and comparisons;

679

(c) The American dental association accepted dental	680
therapeutics;	681

(d) The United States pharmacopoeia drug information.

682

(5) Findings, studies or research conducted by or under the	683
auspices of a federal government agency or nationally recognized	684
federal research institute, including any of the following:	685

(a) The federal agency for health care research and quality;

686

(b) The national institutes of health;

687

(c) The national cancer institute;

688

(d) The national academy of sciences;

689

(e) The centers for medicare and medicaid services;

690

(f) The federal food and drug administration;

691

(g) Any national board recognized by the national institutes	692
of health for the purpose of evaluating the medical value of	693
health care services.	694

(6) Any other medical or scientific evidence that is	695
comparable.	696

(T) "Person" has the same meaning as in section 3901.19 of	697
the Revised Code.	698

(U) "Protected health information" means health information	699
related to the identity of an individual, or information that	700
could reasonably be used to determine the identity of an	701
individual.	702

(V) "Rescission" means a cancellation or discontinuance of	703
coverage that has a retroactive effect. "Rescission" does not	704
include a cancellation or discontinuance of coverage that has only	705
a prospective effect or a cancellation or discontinuance of	706
coverage that is effective retroactively to the extent it is	707
attributable to a failure to timely pay required premiums or	708
contributions towards the cost of coverage.	709

(W) "Retrospective review" means a review conducted after	710
services have been provided to a covered person.	711

(X) "Superintendent" means the superintendent of insurance.

712

(Y) "Utilization review" has the same meaning as in section	713
1751.77 of the Revised Code.	714

(Z) "Utilization review organization" has the same meaning as	715
in section 1751.77 of the Revised Code.	716

Sec. 3922.02.  (A) A covered person may make a request for an	717
external review of an adverse benefit determination.	718

(B) All requests for external review shall be made in	719
writing, except when making a request for an expedited review	720
under section 3922.09 of the Revised Code, by the covered person	721
within one hundred eighty days of the date of the final adverse	722
benefit determination in a form prescribed by the superintendent.	723
Requests for an expedited review may be requested orally or by	724
electronic means. When an oral or electronic request for review is	725
made, written confirmation of the request must be submitted to the	726
health plan issuer no later than five days after the initial	727
request was made.	728

(C) An adverse benefit determination shall be eligible for	729
internal appeal or external review, regardless of how small the	730
cost of the requested health care service related to the adverse	731
benefit determination is.	732

Sec. 3922.03.  (A) All health plan issuers shall implement an	733
internal appeal process under which a covered person may appeal an	734
adverse benefit determination. This process must be in compliance	735
with the Patient Protection and Affordable Care Act of 2010, Pub.	736
L. 111-148, 124 Stat. 119, as amended, and the associated	737
regulations, as well as any other applicable state rules or	738
federal regulations.	739

(B) Review of a final adverse benefit determination shall be	740
through an external review under section 3922.08, 3922.09, or	741
3922.10 of the Revised Code.	742

(C) All health plan issuers shall provide notice to covered	743
persons, pursuant to and in accordance with federal regulations,	744
of all internal appeal processes, external review processes, the	745
availability of any applicable office of health insurance	746
assistance, ombudsman program, or other similar program in this	747
state to assist consumers.	748

Sec. 3922.04.  (A) Except as provided in division (E) of this	749
section, a health plan issuer is not required to grant a request	750
for a standard external review made under section 3922.08 or	751
3922.10 of the Revised Code until the covered person has exhausted	752
the health plan issuer's internal appeal process.	753

(B) An internal appeal process shall be considered exhausted	754
if a covered person has requested an internal appeal and has not	755
received a written decision from the health plan issuer within the	756
time frame required by 23 C.F.R. 2560.503-1 or the health plan	757
issuer fails to adhere to all requirements of the internal appeals	758
process.	759

(C) Notwithstanding division (B) of this section, the	760
internal appeals process will not be deemed exhausted based on de	761
minimis violations that do not cause, and are not likely to cause,	762
prejudice or harm to the covered person so long as the health plan	763
issuer demonstrates that the violation was for good cause or due	764
to matters beyond the control of the health plan issuer and that	765
the violation occurred in the context of an ongoing, good faith	766
exchange of information between the health plan issuer and the	767
covered person, and is not reflective of a pattern or practice of	768
noncompliance, except that:	769

(1) If the health plan issuer denies a request for external	770
review under this division, the covered person may request written	771
explanation from the health plan issuer, and the health plan	772
issuer shall provide the explanation within ten days, including a	773
specific description of its bases, if any, for asserting that the	774
delay should not cause the internal appeals process to be	775
considered exhausted;	776

(2) The covered person may request review by the	777
superintendent of the health plan issuer's explanation provided	778
under division (C)(1) of this section and if the superintendent	779
affirms the health plan issuer's explanation, the covered person	780
may, within ten days of the superintendent's notice of decision,	781
resubmit and pursue the internal appeal process. Time periods for	782
refiling the internal appeal shall begin to run upon receipt of	783
such notice by the covered person.	784

(D) Notwithstanding division (B) of this section, a covered	785
person shall not make a request for an external review of an	786
adverse benefit determination involving a retrospective review	787
determination made pursuant to a utilization review until the	788
covered person has exhausted the health plan issuer's internal	789
appeals process.	790

(E) A request for an external review of an adverse benefit	791
determination may be made before the covered person has exhausted	792
the health plan issuer's internal appeals procedures whenever the	793
health plan issuer agrees to waive the exhaustion requirement. If	794
the internal appeal process is waived, the covered person may file	795
a request in writing for a standard external review under section	796
3922.08 or 3922.10 of the Revised Code.	797

(F) Notwithstanding any other section in this chapter, health	798
plan issuers offering individual health insurance coverage,	799
including coverage offered to individuals through nonemployer	800
groups shall not require more than one level of internal appeal	801
before the individual may request an external review.	802

Sec. 3922.05.  (A) A health plan issuer shall afford the	803
opportunity for an external review by an independent review	804
organization for an adverse benefit determination if the	805
determination involved a medical judgment or if the decision was	806
based on any medical information, pursuant to the following	807
sections:	808

(1) Section 3922.08 of the Revised Code for a standard	809
review;	810

(2) Section 3922.09 of the Revised Code for an expedited	811
review;	812

(3) Section 3922.10 of the Revised Code for reviews involving	813
experimental procedures.	814

(B) A health plan issuer shall afford the opportunity for an	815
external review by the superintendent of insurance for an adverse	816
benefit determination by the health plan issuer based on a	817
contractual issue that did not involve a medical judgment or any	818
medical information, pursuant to section 3922.11 of the Revised	819
Code.	820

(C) For an adverse benefit determination in which emergency	821
medical services have been determined to be not medically	822
necessary or appropriate after an external review pursuant to	823
division (A) of this section, the health plan issuer shall afford	824
the covered person the opportunity for an external review by the	825
superintendent of insurance, based on the prudent layperson	826
standard, pursuant to section 3922.11 of the Revised Code.	827

(D) Upon receipt of a request for an external review from a	828
covered person, the health plan issuer shall review it for	829
completeness as prescribed under any associated rules, policies,	830
or procedures adopted by the superintendent.	831

(1) If the request is complete, the health plan issuer shall	832
initiate an external review in accordance with any associated	833
rules, policies, or procedures adopted by the superintendent of	834
insurance and shall notify the covered person in writing, in a	835
form specified by the superintendent of insurance, that the	836
request is complete. This notification shall include both of the	837
following:	838

(a) The name and contact information for the assigned	839
independent review organization or the superintendent of	840
insurance, as applicable, for the purpose of submitting additional	841
information;	842

(b) Except for when an expedited request is made under	843
section 3922.09 or 3922.10 of the Revised Code, a statement that	844
the covered person may, with ten business days after the date of	845
receipt of the notice, submit, in writing, additional information	846
for either the independent review organization or the	847
superintendent of insurance to consider when conducting the	848
external review.	849

(2) If the request for an external review is not complete,	850
the health plan issuer shall, in accordance with any associated	851
rules, policies, or procedures adopted by the superintendent of	852
insurance, inform the covered person in writing, including what	853
information is needed to make the request complete.	854

(E)(1) If the health plan issuer denies a request for an	855
external review on the basis that the adverse benefit	856
determination is not eligible for an external review, the health	857
plan issuer shall notify the covered person in writing of both of	858
the following:	859

(a) The reason for the denial;

860

(b) That the denial may be appealed to the superintendent.

861

(2) If the health plan issuer denies a request for external	862
review on the basis that the adverse benefit determination is not	863
eligible for an external review, the covered person may appeal the	864
denial to the superintendent of insurance.	865

(3) Regardless of a determination made by a health plan	866
issuer, the superintendent of insurance may determine that a	867
request is eligible for external review. The superintendent's	868
determination shall be made in accordance with the terms of the	869
covered person's benefit plan and shall be subject to all	870
applicable provisions of this chapter.	871

(F)(1) If an external review of an adverse benefit	872
determination is granted, the superintendent, according to any	873
rules, policies, or procedures adopted by the superintendent shall	874
assign an independent review organization from the list of	875
organizations maintained by the superintendent under section	876
3922.13 of the Revised Code to conduct the external review and	877
shall notify the health plan issuer of the name of the assigned	878
independent review organization.	879

(2) The assignment of an approved independent review	880
organization shall be done on a random basis from those	881
independent review organizations qualified to conduct the review	882
in question based on the nature of the health care service that is	883
the subject of the adverse benefit determination.	884

(3) The superintendent of insurance shall not choose an	885
independent review organization with a conflict of interest, as	886
prescribed under section 3922.14 of the Revised Code.	887

(G) In its review of an adverse benefit determination under	888
section 3922.08, 3922.09, or 3922.10 of the Revised Code, an	889
assigned independent review organization is not bound by any	890
decisions or conclusions reached by the health plan issuer during	891
its utilization review process or internal appeals process. The	892
organization is not required to, but may, accept and consider	893
additional information submitted after the end of the	894
ten-business-day period described in division (D)(1)(b) of this	895
section.	896

(H)(1) An independent review organization assigned to review	897
an adverse benefit determination shall provide written notice of	898
its decision to either uphold or reverse the determination within	899
thirty days of receipt of a request for a standard review or a	900
standard review involving an experimental or investigational	901
treatment, or within seventy-two hours of receipt of an expedited	902
request.	903

(2) The written notice shall be sent to all of the following:

904

(a) The covered person;

905

(b) The health plan issuer;

906

(c) The superintendent of insurance.

907

(3) The written notification shall include all of the	908
following:	909

(a) A general description of the reason for the request for	910
external review;	911

(b) The date the independent review organization was assigned	912
by the superintendent of insurance to conduct the external review;	913

(c) The dates over which the external review was conducted;

914

(d) The date on which the independent review organization's	915
decision was made;	916

(e) The rationale for its decision;

917

(f) References to the evidence or documentation, including	918
any evidence-based standards used, that were considered in	919
reaching its decision.	920

(I) Upon receipt of a notice by an independent review	921
organization to reverse the adverse benefit determination, a	922
health plan issuer shall immediately provide coverage for the	923
health care service or services in question.	924

Sec. 3922.06. Except for when an expedited request is made	925
under section 3922.09 or 3922.10 of the Revised Code, an	926
independent review organization shall forward upon receipt a copy	927
of any information received from a covered person pursuant to	928
division (D)(1) of section 3922.05 of the Revised Code, as well as	929
any other information received from the covered person, to the	930
health plan issuer.	931

Upon receipt of that information or the information described	932
in division (K) of section 3922.10 of the Revised Code, a health	933
plan issuer may reconsider its adverse benefit determination and	934
provide coverage for the health service in question.	935

Reconsideration of an adverse benefit determination by a	936
health plan issuer receipt of information under this section shall	937
not delay or terminate an external review.	938

If a health plan issuer reverses an adverse benefit	939
determination under this section, the health plan issuer shall	940
notify, in writing and within one business day of making such a	941
decision, the covered person, the assigned independent review	942
organization, and the superintendent of insurance.	943

Upon receipt of such a notification, the assigned independent	944
review organization shall terminate the associated external	945
review.	946

Sec. 3922.07.  In addition to the information provided under	947
division (D)(1)(b) of section 3922.05, division (B) of section	948
3922.08, division (C) of section 3922.09, and division (D) of	949
section 3922.10 of the Revised Code, an assigned independent	950
review organization, to the extent that such documents are	951
available and appropriate, shall consider all of the following	952
when conducting its review:	953

(A) The covered person's medical records;

954

(B) The attending health care professional's recommendation;

955

(C) Consulting reports from appropriate health care	956
professionals and other documents submitted by the health plan	957
issuer, covered person, or covered person's treating provider;	958

(D) The terms of coverage under the covered person's health	959
benefit plan to ensure that the independent review organization's	960
decision is not contrary to the terms of the plan;	961

(E) The most appropriate practice guidelines, including	962
evidence-based standards, and practice guidelines developed by the	963
federal government, and national or professional medical	964
societies, boards, and associations;	965

(F) Any applicable clinical review criteria developed and	966
used by the health plan issuer or its designated utilization	967
review organization;	968

(G) The opinion of the independent review organization's	969
clinical reviewer or reviewers after considering the other sources	970
described in this section.	971

Sec. 3922.08.  (A) The provisions of this section apply only	972
to standard reviews, which are not expedited and do not involve an	973
experimental or investigational treatment.	974

(B) Within five days after the receipt of a request for an	975
external review that is complete and valid, the health plan issuer	976
shall provide to the assigned independent review organization all	977
documents and information considered in making the adverse benefit	978
determination.	979

(C) An external review shall not be delayed due to failure on	980
the part of the health plan issuer to provide the information	981
required under division (B) of this section.	982

(D)(1) An independent review organization may reverse an	983
adverse benefit determination if the information required under	984
division (B) of this section is not provided in the allotted time.	985
The independent review organization may also grant a request from	986
the health plan issuer for more time to provide the required	987
information.	988

(2) If an adverse benefit determination is reversed under	989
division (D)(1) of this section, the independent review	990
organization shall notify, within one business day of making the	991
decision, the covered person, the health plan issuer, and the	992
superintendent of insurance.	993

Sec. 3922.09.  (A) A covered person may make a request for an	994
expedited external review, except as provided in division (J) of	995
this section:	996

(1) After an adverse benefit determination, if both of the	997
following apply:	998

(a) The covered person's treating physician certifies that	999
the adverse benefit determination involves a medical condition	1000
that could seriously jeopardize the life or health of the covered	1001
person if treated after the time frame of an expedited internal	1002
review;	1003

(b) The covered person has filed a request for an expedited	1004
internal review.	1005

(2) After a final adverse benefit determination, if either of	1006
the following apply:	1007

(a) The covered person's treating physician certifies that	1008
the adverse benefit determination involves a medical condition	1009
that could seriously jeopardize the life or health of the covered	1010
person, or would jeopardize the covered person's ability to regain	1011
maximum function, if treated after the time frame of a standard	1012
external review;	1013

(b) The final adverse benefit determination concerns an	1014
admission, availability of care, continued stay, or health care	1015
service for which the covered person received emergency services,	1016
but has not yet been discharged from a facility.	1017

(B) Immediately upon receipt of a request for an expedited	1018
external review, the health plan issuer shall determine if the	1019
request is complete under any associated rules, policies, or	1020
procedures adopted by the superintendent of insurance and eligible	1021
for expedited external review under division (B) of this section.	1022
The health plan issuer shall immediately notify the covered person	1023
of its determination in accordance with any associated rules,	1024
policies, or procedures adopted by the superintendent of	1025
insurance.	1026

(C) If a request for an expedited review is complete and	1027
eligible, the health plan issuer shall immediately provide or	1028
transmit all necessary documents and information considered in	1029
making the adverse benefit determination in question to the	1030
assigned independent review organization electronically, or by	1031
telephone, facsimile, or other available expeditious method.	1032

(D) In addition to the information transmitted under division	1033
(D) of this section, the assigned independent review organization	1034
shall also consider relevant information as required under section	1035
3922.07 of the Revised Code.	1036

(E) As expeditiously as the covered person's medical	1037
condition requires, but no more than seventy-two hours after being	1038
assigned an expedited, external review, the assigned independent	1039
review organization shall uphold or reverse the adverse benefit	1040
determination.	1041

(F) If a health plan issuer fails to provide the documents	1042
and information as required in division (D) of this section, the	1043
independent review organization shall not delay the external	1044
review and may accordingly reverse the adverse benefit	1045
determination.	1046

(G) An independent review organization shall promptly notify	1047
the covered person, health plan issuer, and superintendent of	1048
insurance of any decision made under this section. If such a	1049
notice is not made in writing, the independent review	1050
organization, shall provide, within forty-eight hours of making	1051
the decision, written confirmation, including the information	1052
required under division (H)(3) of section 3922.05 of the Revised	1053
Code, of its decision to the covered person, the health plan	1054
issuer, and the superintendent of insurance.	1055

(H) Upon receipt of a notice by an independent review	1056
organization to reverse the adverse benefit determination, a	1057
health plan issuer shall immediately provide coverage for the	1058
health care service or services in question.	1059

(I) An expedited, external review may not be provided for	1060
retrospective final adverse benefit determinations.	1061

Sec. 3922.10.  The provisions of this section apply only to	1062
external reviews that involve an experimental or investigational	1063
treatment.	1064

(A) A covered person may request an external review of an	1065
adverse benefit determination based on the conclusion that a	1066
requested health care service is experimental or investigational,	1067
except when the requested health care service is explicitly listed	1068
as an excluded benefit under the covered person's benefit plan.	1069

(B) To be eligible for an external review under this section,	1070
a covered person's treating physician shall certify that one of	1071
the following situations is applicable:	1072

(1) Standard health care services have not been effective in	1073
improving the condition of the covered person;	1074

(2) Standard health care services are not medically	1075
appropriate for the covered person;	1076

(3) There is no available standard health care services	1077
covered by the health plan issuer that is more beneficial than	1078
requested health care service.	1079

(C)(1) A covered person may request orally or by electronic	1080
means an expedited review under this section if the person's	1081
treating physician certifies that the requested health care	1082
service in question would be significantly less effective if not	1083
promptly initiated.	1084

(2) Immediately upon receipt of a request for an expedited	1085
external review, the health plan issuer shall determine if the	1086
request is complete under any associated rules, policies, or	1087
procedures adopted by the superintendent of insurance and eligible	1088
for expedited external review under division (B) of this section.	1089
The health plan issuer shall immediately notify the covered person	1090
of its determination in accordance with any associated rules	1091
adopted by the superintendent of insurance.	1092

(D) The health plan issuer shall provide to the assigned	1093
independent review organization all documents and information	1094
considered in making the adverse benefit determination within	1095
whichever of the following applies:	1096

(1) Within five days after the receipt of a request for an	1097
external review;	1098

(2) For an expedited external review, immediately by	1099
telephone, facsimile, or any other available expeditious method.	1100

(E) An independent review organization assigned by the	1101
superintendent of insurance under division (F) of section 3922.05	1102
of the Revised Code shall do both of the following:	1103

(1) Select at least one clinical reviewer, pursuant to	1104
divisions (F) and (G) of this section to conduct the external	1105
review;	1106

(2) Make a decision to uphold or reverse the adverse benefit	1107
determination based upon the opinion of the clinical reviewer or	1108
reviewers.	1109

(F) In selecting clinical reviewers under division (E) of	1110
this section, the assigned independent review organization shall	1111
select physicians or other health care professionals who meet the	1112
minimum qualifications described in section 3922.15 of the Revised	1113
Code, and through clinical experience in the last three years, are	1114
experts in the treatment of the covered person's condition and	1115
have knowledge of the requested health care service.	1116

(G) Neither the covered person, nor the health plan issuer,	1117
shall choose or have any influence over the choice of the clinical	1118
reviewer or reviewers chosen under division (E) of this section.	1119

(H)(1) Each chosen clinical reviewer shall provide a written	1120
opinion to the assigned independent review organization on whether	1121
the adverse benefit determination should be upheld or reversed.	1122

(2) In reaching such opinions, a clinical reviewer is not	1123
bound by any conclusions reached by the health plan issuer during	1124
a utilization review process or its internal appeals process.	1125

(3) Any such opinion shall be in writing and shall include	1126
all of the following information:	1127

(a) A description of the covered person's condition;

1128

(b) A description of the indicators relevant to determining	1129
whether there is sufficient evidence to demonstrate that the	1130
recommended or requested therapy is more likely than not to be	1131
more beneficial to the covered person than any available standard	1132
health care service, and that the adverse risks of the requested	1133
health care service would not be substantially greater than those	1134
of available standard health care services;	1135

(c) A description and analysis of any medical or scientific	1136
evidence considered in reaching the opinion;	1137

(d) A description and analysis of any evidence-based standard	1138
considered;	1139

(e) Information on whether the reviewer's rationale for the	1140
opinion is based on division (L)(2) or (L)(3) of this section.	1141

(I) An external review shall not be delayed due to failure on	1142
the part of the health plan issuer to provide the information	1143
required under division (D) of this section.	1144

(J)(1) An independent review organization may reverse an	1145
adverse benefit determination, if the information required under	1146
division (D) of this section is not provided in the allotted time.	1147
The external review committee may also grant a request from the	1148
health plan issuer for more time to provide the required	1149
information.	1150

(2) If an adverse benefit determination is reversed under	1151
division (J)(1) of this section, the independent review	1152
organization shall immediately notify the covered person, the	1153
health plan issuer, and the superintendent of insurance.	1154

(K)(1) Each clinical reviewer shall review all of the	1155
information received pursuant to division (D) of this section, as	1156
well as any other information submitted in writing by the covered	1157
person pursuant to division (D) of section 3922.05 of the Revised	1158
Code.	1159

(2) In addition to the documents and information provided	1160
pursuant to division (D) of this section and division (D) of	1161
section 3922.05 of the Revised Code, each clinical reviewer shall	1162
consider the following:	1163

(a) Information required under section 3922.07 of the Revised	1164
Code;	1165

(b) Whether the requested health care service has been	1166
approved by the federal food and drug administration, if	1167
applicable, for the condition;	1168

(c) Whether medical or scientific evidence, or evidence-based	1169
standards, demonstrate that the expected benefits of the requested	1170
health care service is more likely than not to be beneficial to	1171
the covered person than any available standard health care	1172
service, and that the adverse risks of the requested health care	1173
service would not be substantially greater than those of available	1174
standard health care services.	1175

(L) Within one business day after the receipt of any such	1176
information submitted by the covered person in accordance with	1177
division (K)(1) of this section, the independent review	1178
organization shall forward the information to the health plan	1179
issuer. Upon receipt of any such forwarded information in	1180
accordance with division (K)(1) of this section, a health plan	1181
issuer may reconsider its adverse benefit determination under	1182
section 3922.06 of the Revised Code.	1183

(M)(1) Within thirty days after the date of receipt of a	1184
request for a standard external review, or within seventy-two	1185
hours of receipt of a request for an expedited external review,	1186
the assigned independent review organization shall provide written	1187
notice of its decision to uphold or reverse the adverse benefit	1188
determination to the covered person, the health plan issuer, and	1189
the superintendent of insurance.	1190

(2)(a) If a majority of the clinical reviewers recommend that	1191
the requested health care service should be covered, the	1192
independent review organization shall make a decision to reverse	1193
the health plan issuer's adverse benefit determination.	1194

(b) If a majority of the clinical reviewers recommend that	1195
the recommended or requested health care service or treatment	1196
should not be covered, the independent review organization shall	1197
make a decision to uphold the health plan issuer's adverse benefit	1198
determination.	1199

(c)(i) If the clinical reviewers are evenly split as to	1200
whether the adverse benefit determination should be reversed or	1201
upheld, the independent review organization shall obtain the	1202
opinion of an additional clinical reviewer in order for the	1203
independent review organization to make a decision based on the	1204
opinions of a majority of the clinical reviewers pursuant to this	1205
division.	1206

(ii) The additional clinical reviewer selected shall use the	1207
same information to reach an opinion as the clinical reviewers who	1208
have already submitted their opinions pursuant to this section.	1209

(iii) The selection of the additional clinical reviewer under	1210
this division shall not extend the time within which the assigned	1211
independent review organization is required to make a decision.	1212

(3) The independent review organization shall include in the	1213
notice provided pursuant to division (M)(1) of this section all of	1214
the following:	1215

(a) A general description of the reason for the request for	1216
external review;	1217

(b) The written opinion of each clinical reviewer, including	1218
the recommendation of each clinical reviewer as to whether the	1219
recommended or requested health care service or treatment should	1220
be covered and the rationale for that recommendation;	1221

(c) The date the independent review organization was assigned	1222
by the superintendent to conduct the external review;	1223

(d) The dates over which the external review was conducted;

1224

(e) The date of its decision;

1225

(f) The principal reason or reasons for its decision;

1226

(g) The rationale for its decision.

1227

(N) Upon receipt of a notice of a decision by an independent	1228
review organization pursuant to division (M)(1) of this section	1229
reversing the adverse benefit determination, a health plan issuer	1230
shall immediately provide coverage of the requested health care	1231
service in question.	1232

Sec. 3922.11.  (A) The superintendent of insurance shall	1233
establish and maintain a system for receiving and reviewing	1234
requests for external review for adverse benefit determinations	1235
where the determination by the health plan issuer was based on a	1236
contractual issue and did not involve a medical judgment or a	1237
determination based on any medical information, except for	1238
emergency services, as specified in division (C) of section	1239
3922.05 of the Revised Code.	1240

(B) A health plan issuer shall submit a request for external	1241
review pursuant to division (B) or (C) of section 3922.05 of the	1242
Revised Code to the superintendent, in accordance with any	1243
associated rules, policies, or procedures adopted by the	1244
superintendent of insurance.	1245

(C) On receipt of a request from a health plan issuer, the	1246
superintendent shall consider whether the health care service is a	1247
service covered under the terms of the covered person's policy,	1248
contract, certificate, or agreement, except that the	1249
superintendent shall not conduct a review under this section	1250
unless the covered person has exhausted the health plan issuer's	1251
internal review process, pursuant to sections 3922.03 and 3922.04	1252
of the Revised Code. The health plan issuer and covered person	1253
shall provide the superintendent with any information required by	1254
the superintendent that is in their possession and is germane to	1255
the review.	1256

(D) Unless the superintendent is not able to do so because	1257
making the determination requires a medical judgement or a	1258
determination based on medical information, the superintendent	1259
shall determine whether the health care service at issue is a	1260
service covered under the terms of the covered person's contract,	1261
policy, certificate, or agreement. The superintendent shall notify	1262
the covered person, and the health plan issuer of the	1263
superintendent's determination.	1264

(E) If the superintendent notifies the health plan issuer	1265
that making the determination requires a medical judgement or a	1266
determination based on medical information, the health plan issuer	1267
shall initiate an external review under this chapter.	1268

(F) If the superintendent determines that the health service	1269
is a covered service, the health plan issuer shall cover the	1270
service.	1271

(G) If the superintendent determines that the health care	1272
service is not a covered service, the health plan issuer is not	1273
required to cover the service or afford the enrollee an external	1274
review.	1275

Sec. 3922.12.  (A) An external review decision is binding on	1276
the health plan issuer except to the extent the health plan issuer	1277
has other remedies available under applicable state law, or unless	1278
the superintendent of insurance determines that, due to the facts	1279
and circumstances of an external review, a second external review	1280
is required.	1281

(B) An external review decision is binding on the covered	1282
person except to the extent the covered person has other remedies	1283
available under applicable federal or state law, or unless the	1284
superintendent determines that, due to the facts and circumstances	1285
of an external review, a second external review is required.	1286

(C) A covered person may not file a subsequent request for	1287
external review involving the same adverse benefit determination	1288
for which the covered person has already received an external	1289
review decision pursuant to this chapter, except in the event that	1290
new medical or scientific evidence is submitted to the health plan	1291
issuer.	1292

Sec. 3922.13.  The superintendent shall accredit independent	1293
review organizations as prescribed by this section.	1294

(A) The superintendent shall develop an application form to	1295
accredit and renew accreditation of an independent review	1296
organization.	1297

(B) An independent review organization seeking to be	1298
accredited by the superintendent, or to renew its accreditation,	1299
shall submit the application form and include with the form all	1300
documentation and information necessary for the superintendent to	1301
determine if the independent review organization satisfies the	1302
minimum qualifications established under section 3922.14 of the	1303
Revised Code.	1304

(C)(1) Except as provided in division (C)(2) of this section,	1305
an independent review organization is eligible for accreditation	1306
by the superintendent under this section only if it is accredited	1307
by a nationally recognized private accrediting entity that the	1308
superintendent has determined has accreditation standards that are	1309
equivalent to or exceed the minimum qualifications for independent	1310
review organizations under section 3922.14 of the Revised Code.	1311

(2) The superintendent may approve independent review	1312
organizations that are not accredited by a nationally recognized	1313
private accrediting entity, if there are no acceptable nationally	1314
recognized private accrediting entities providing independent	1315
review organization accreditation.	1316

(D) An independent review organization shall apply to renew	1317
its accreditation on an annual basis.	1318

(E) If the superintendent determines that an independent	1319
review organization has lost its accreditation by a nationally	1320
recognized private accrediting entity or no longer satisfies the	1321
minimum requirements established under section 3922.14 of the	1322
Revised Code, the superintendent shall revoke the independent	1323
review organization's accreditation and shall remove the	1324
independent review organization from the list of independent	1325
review organizations approved to conduct external reviews.	1326

(F) The superintendent shall maintain and periodically update	1327
a list of accredited independent review organizations.	1328

Sec. 3922.14.  (A) To be accredited by the superintendent of	1329
insurance to conduct external reviews under section 3922.13 of the	1330
Revised Code, in addition to the requirements provided in section	1331
3922.13 of the Revised Code and any associated rules adopted by	1332
the superintendent, an independent review organization shall do	1333
all of the following:	1334

(1) Develop and maintain written policies and procedures that	1335
govern all aspects of both the standard external review process	1336
and the expedited external review process set forth in this	1337
chapter, including a quality assurance mechanism that does all of	1338
the following:	1339

(a) Ensures that external reviews are conducted within the	1340
time frames prescribed under this chapter and that the required	1341
notices are provided in a timely manner;	1342

(b) Ensures the selection of qualified and impartial	1343
clinical reviewers to conduct external reviews on behalf of the	1344
independent review organization;	1345

(c) Ensures that chosen clinical reviewers are suitably	1346
matched according to their area of expertise to specific cases and	1347
that the independent review organization employs or contracts with	1348
an adequate number of clinical reviewers to meet this requirement;	1349

(d) Ensures the confidentiality of medical and treatment	1350
records and clinical review criteria;	1351

(e) Ensures that any person employed by, or who is under	1352
contract with, the independent review organization adheres to the	1353
requirements of this chapter.	1354

(2) Maintain a toll-free telephone service to receive	1355
information on a twenty-four-hour-a-day, seven-days-a-week basis	1356
related to external reviews that is capable of accepting,	1357
recording, and providing appropriate instruction to incoming	1358
telephone callers during other than normal business hours;	1359

(3) Agree to maintain and provide to the superintendent, upon	1360
request and in accordance with any associated rules, policies, or	1361
procedures adopted by the superintendent of insurance, the	1362
information prescribed in section 3922.17 of the Revised Code.	1363

(B) An independent review organization may not own or	1364
control, be a subsidiary of or in any way be owned or controlled	1365
by, or exercise control with a benefit plan, a national, state or	1366
local trade association of benefit plans, or a national, state, or	1367
local trade association of health care providers.	1368

(C)(1) Neither the independent review organization selected	1369
to conduct the external review nor any clinical reviewer assigned	1370
by the independent organization to conduct the external review may	1371
have a material, professional, familial, or financial affiliation	1372
with any of the following:	1373

(a) The health plan issuer that is the subject of the	1374
external review, or any officer, director, or management employee	1375
of the health plan issuer;	1376

(b) The covered person whose treatment is the subject of the	1377
external review;	1378

(c) The health care provider, or the health care provider's	1379
medical group or independent practice association, recommending	1380
the health care service or treatment that is the subject of the	1381
external review;	1382

(d) The facility at which the recommended health care service	1383
would be provided;	1384

(e) The developer or manufacturer of the principal drug,	1385
device, procedure, or other therapy being recommended for the	1386
covered person whose treatment is the subject of the external	1387
review.	1388

(2) The superintendent may make a determination as to whether	1389
an independent review organization or a clinical reviewer of the	1390
independent review organization has a material professional,	1391
familial, or financial conflict of interest for purposes of	1392
division (C)(1) of this section. In making this determination, the	1393
superintendent may take into consideration situations where an	1394
independent review organization, or a clinical reviewer, may have	1395
an apparent conflict of interest, but that the characteristics of	1396
the relationship or connection in question are such that they do	1397
not fall under the definition of conflict of interest provided	1398
under division (D)(1) of this section. If the superintendent	1399
determines that a conflict of interest exists, the superintendent	1400
shall disallow an independent review organization or a clinical	1401
reviewer from conducting the external review in question. Such	1402
determinations related to conflicts of interest are the sole	1403
discretion of the superintendent of insurance.	1404

(D)(1) An independent review organization that is accredited	1405
by a nationally recognized private accrediting entity that has	1406
independent review accreditation standards that the superintendent	1407
has determined are equivalent to or exceed the minimum	1408
qualifications of this section shall be presumed in compliance	1409
with this section to be eligible for accreditation by the	1410
superintendent under section 3922.14 of the Revised Code.	1411

(2) The superintendent shall initially review and	1412
periodically review the independent review organization	1413
accreditation standards of a nationally recognized private	1414
accrediting entity to determine whether the entity's standards	1415
are, and continue to be, equivalent to or exceed the minimum	1416
qualifications established under this section. The superintendent	1417
may accept a review conducted by the national association of	1418
insurance commissioners for the purpose of the determination under	1419
this division.	1420

(3) Upon request, a nationally recognized, private	1421
accrediting entity shall make its current independent review	1422
organization accreditation standards available to the	1423
superintendent or the national association of insurance	1424
commissioners in order for the superintendent to determine if the	1425
entity's standards are equivalent to or exceed the minimum	1426
qualifications established under this section. The superintendent	1427
may exclude any private accrediting entity that is not reviewed by	1428
the national association of insurance commissioners.	1429

(E) An independent review organization shall be unbiased in	1430
its review of adverse benefit determinations and shall establish	1431
and maintain written procedures to ensure that it is unbiased.	1432

Sec. 3922.15.  All clinical reviewers assigned by an	1433
independent review organization to conduct external reviews shall	1434
have the same license as the health care provider of the service	1435
in question, and shall be physicians or other appropriate health	1436
care providers who meet all of the following minimum	1437
qualifications:	1438

(A) Be an expert in the treatment of the medical condition	1439
that is the subject of the external review;	1440

(B) Be knowledgeable about the requested health care service	1441
through clinical experience, within the last three years, treating	1442
patients with the same, or a similar, medical condition;	1443

(C) Hold a nonrestricted license in a state of the United	1444
States and, for physicians, a current certification by a	1445
recognized American medical specialty board in the area or areas	1446
appropriate to the subject of the external review;	1447

(D) Have no history of disciplinary actions or sanctions,	1448
including loss of staff privileges or participation restrictions,	1449
that have been taken or are pending by any hospital, governmental	1450
agency or unit, or regulatory body that raise a question as to the	1451
clinical reviewer's physical, mental, or professional competence	1452
or moral character.	1453

Sec. 3922.16.  (A) Nothing in this chapter shall be construed	1454
to create a cause of action against any of the following:	1455

(1) An employer that provides health care benefits to	1456
employees through a health plan issuer;	1457

(2) A clinical reviewer, medical expert, or independent	1458
review organization that participates in an external review under	1459
this chapter;	1460

(3) A health plan issuer that provides coverage for benefits	1461
pursuant to this chapter.	1462

(B) An independent review organization and any medical expert	1463
or clinical reviewer an independent review organization uses in	1464
conducting an external review under this chapter is not liable in	1465
damages in a civil action for injury, death, or loss to person or	1466
property and is not subject to professional disciplinary action	1467
for making, in good faith, any finding, conclusion, or	1468
determination required to complete the external review.	1469

(C) This section does not grant immunity from civil liability	1470
or professional disciplinary action to an independent review	1471
organization, medical expert, or clinical peer for an action that	1472
is outside the scope of authority granted under this chapter.	1473

Sec. 3922.17.  (A)(1) An independent review organization	1474
assigned pursuant to sections 3922.08, 3922.09, or 3922.10 of the	1475
Revised Code to conduct an external review shall maintain written	1476
records in accordance with the associated rules established by the	1477
superintendent, in the aggregate by state, and by the health plan	1478
issuer, on all external reviews requested and conducted during a	1479
calendar year.	1480

Each independent review organization shall submit this	1481
information to the superintendent, upon request, in a report in	1482
the format specified by the superintendent that shall include, in	1483
the aggregate by state and for each health plan issuer, all of the	1484
following:	1485

(a) The total number of requests for external review;

1486

(b) The number of requests for external review resolved and,	1487
of those resolved, the number upholding and the number reversing	1488
an adverse benefit determination;	1489

(c) The average length of time for a resolution;

1490

(d) A summary of the types of requested health care services	1491
or cases for which an external review was sought;	1492

(e) The number of external reviews that were terminated as	1493
the result of a reconsideration by the health plan issuer of an	1494
adverse benefit determination after the receipt of additional	1495
information from the covered person under section 3922.05 of the	1496
Revised Code;	1497

(f) The costs associated with external reviews, including the	1498
amounts charged by the independent review organization to conduct	1499
the reviews;	1500

(g) The medical specialty, or the type, of clinical reviewer	1501
used to conduct each external review, as related to the specific	1502
medical condition of the covered person;	1503

(h) Any other information the superintendent may request or	1504
require.	1505

(2) The independent review organization shall retain the	1506
written records required under division (A)(1) of this section for	1507
at least three years.	1508

(B) A health plan issuer shall maintain written records on	1509
all requests made for an external review under this chapter and	1510
shall provide all such information as required by any associated	1511
rules, policies, or procedures adopted by the superintendent of	1512
insurance. A health plan issuer shall maintain written records on	1513
all requests for external review for at least three years.	1514

(C) The superintendent shall compile and annually publish the	1515
information collected under this section and report the	1516
information to the governor, the speaker and minority leader of	1517
the house of representatives, the president and minority leader of	1518
the senate, and the chairs and ranking minority members of the	1519
house and senate committees with jurisdiction over health and	1520
insurance issues.	1521

Sec. 3922.18.  The health plan issuer against which a request	1522
for a standard external review or an expedited external review is	1523
filed shall pay the cost of the external review, including the	1524
cost of any external review that is required at the direction of	1525
the superintendent.	1526

If the superintendent determines that, due to the facts and	1527
circumstances of an external review, a second external review is	1528
required, the health plan issuer shall pay the costs of the second	1529
review.	1530

Sec. 3922.19.  (A) Each health plan issuer shall include a	1531
description of its external review procedures, including the	1532
superintendent's contractual review, in, or attached to, the	1533
policy, certificate, membership booklet, or outline of coverage,	1534
or other evidence of coverage it provides to covered persons. This	1535
disclosure shall be in a form prescribed by the superintendent in	1536
any associated rules, policies, or procedures.	1537

(B) The disclosure required by division (A) of this section	1538
shall include a statement that informs the covered person of the	1539
covered person's right to file a request for an external review of	1540
an adverse benefit determination with the health plan issuer. The	1541
statement shall do all of the following:	1542

(1) Explain that external review is available when the	1543
adverse benefit determination involves an issue of medical	1544
necessity, appropriateness, health care setting, and level of care	1545
or effectiveness;	1546

(2) Include the telephone number and address of the	1547
superintendent	1548

(3) Inform the covered person that, when filing a request for	1549
an external review, the covered person will be required to	1550
authorize the release of the covered person's medical records as	1551
necessary to conduct the external review.	1552

(C)(1) When a health plan issuer notifies a covered person of	1553
an adverse benefit determination, the health plan issuer shall	1554
also notify the covered person, in writing, of the covered	1555
person's right to request an external review, pursuant to section	1556
3922.08, 3922.09, 3922.10, or 3922.11 of the Revised Code.	1557

(2) As part of the written notice required under division	1558
(C)(1) of this section, a health plan issuer shall include all of	1559
the following:	1560

(a) Information sufficient to identify the claim or health	1561
care service involved, including the health care provider, and the	1562
date of service and claim amount, if applicable;	1563

(b) A description of the reason or reasons for the adverse	1564
benefit determination, including the denial code, such as the	1565
claim adjustment reason code and the remittance advice remark	1566
code, and each code's corresponding meaning;	1567

(c) A description of the health plan issuer's standard, if	1568
any, that was used in making the determination;	1569

(d) A description of the available internal appeals and	1570
external review processes, including information regarding how to	1571
initiate an appeal and an external review;	1572

(e) Disclosure of the availability of assistance from the	1573
superintendent with the internal appeals and external review	1574
processes, including the web site, telephone number, and mailing	1575
address of the superintendent's office of consumer services.	1576

(3) In the case of a notice of a final adverse benefit	1577
determination subsequent to an internal appeal, in addition to the	1578
information required under division (C)(2) of this section, the	1579
notice must also include a discussion of the decision.	1580

(4) Any written notice provided under division (C) of this	1581
section shall be in a form prescribed by the superintendent of	1582
insurance.	1583

(D) For an adverse benefit determination that is not a final	1584
adverse benefit determination, the health plan issuer shall	1585
include with the notice required under division (C) of this	1586
section a statement informing the covered person of all of the	1587
following:	1588

(1) If the covered person's treating physician certifies in	1589
writing that the covered person has a medical condition where the	1590
time frame for completion of an expedited review of an internal	1591
appeal involving an adverse benefit determination would seriously	1592
jeopardize the life or health of the covered person or jeopardize	1593
the covered person's ability to regain maximum function, the	1594
covered person may file a request for an expedited external review	1595
to be conducted simultaneously with the expedited internal appeal,	1596
pursuant to section 3922.09 of the Revised Code.	1597

(2) If the adverse benefit determination involves a denial of	1598
coverage based on a determination that the recommended or	1599
requested health care service or treatment is experimental or	1600
investigational and the covered person's treating physician	1601
certifies in writing that the recommended or requested health care	1602
service or treatment that is the subject of the adverse benefit	1603
determination would be significantly less effective if not	1604
promptly initiated, the covered person may file a request for an	1605
expedited external review to be conducted simultaneously with the	1606
expedited internal appeal, pursuant to section 3922.09 or 3922.10	1607
of the Revised Code.	1608

(3) If the covered person has requested an internal appeal	1609
and the health plan issuer has not issued a written decision to	1610
the covered person within thirty days following the date the	1611
covered person files the request, and the covered person has not	1612
requested or agreed to a delay, the covered person may file a	1613
request for external review pursuant to section 3922.08 of the	1614
Revised Code and may be considered to have exhausted the health	1615
plan issuer's internal appeals process for purposes of section	1616
3922.04 of the Revised Code.	1617

(E) For a final adverse benefit determination, the health	1618
plan issuer shall include with the notice required under division	1619
(C) of this section a statement informing the covered person of	1620
all of the following:	1621

(1) A written request for an external review must be	1622
submitted to the health plan issuer within one hundred eighty days	1623
after the date of the notice of final adverse benefit	1624
determination;	1625

(2) If the covered person's treating physician certifies in	1626
writing that the covered person has a medical condition for which	1627
the time frame for completion of a standard external review	1628
pursuant to section 3922.08 of the Revised Code would seriously	1629
jeopardize the life or health of the covered person or would	1630
jeopardize the covered person's ability to regain maximum	1631
function, the covered person may file a request for an expedited	1632
external review pursuant to section 3922.09 of the Revised Code.	1633

(3)(a) If the final adverse benefit determination concerns a	1634
health care service for which the covered person received	1635
emergency services, but has not been discharged from a facility,	1636
the covered person may request an expedited external review	1637
pursuant to section 3922.09 of the Revised Code.	1638

(b) If the final adverse benefit determination concerns	1639
denial of coverage based on a determination that the recommended	1640
or requested health care service or treatment is experimental or	1641
investigational, the covered person may file a request for an	1642
external review to be conducted pursuant to section 3922.10 of the	1643
Revised Code, or if the covered person's treating physician	1644
certifies in writing that the recommended or requested health care	1645
service that is the subject of the request would be significantly	1646
less effective if not promptly initiated, the covered person may	1647
request an expedited external review to be conducted under section	1648
3922.10 of the Revised Code.	1649

(F)(1) In addition, any information required to be provided	1650
under divisions (D) and (E) of this section, the health plan	1651
issuer shall include a description of both the standard and	1652
expedited external review procedures the health plan issuer is	1653
required to produce pursuant to this chapter, highlighting in the	1654
external review procedures the sections of the Revised Code that	1655
give the covered person the opportunity to submit additional	1656
information.	1657

(2) The health plan issuer shall also include any forms used	1658
to process an external review, including an authorization form, or	1659
other document approved by the superintendent that complies with	1660
the requirements of 45 C.F.R. 164.508, by which the covered	1661
person, for purposes of conducting an external review under this	1662
chapter, authorizes the health plan issuer and the covered	1663
person's treating health care provider to disclose protected	1664
health information, including medical records, concerning the	1665
covered person that are related in any manner to the external	1666
review.	1667

Sec. 3922.20.  Consistent with the Rules of Evidence, a	1668
written decision or opinion prepared by an independent review	1669
organization under this chapter shall be admissible in any civil	1670
action related to the coverage decision that was the subject of	1671
the decision or opinion. The independent review organization's	1672
decision or opinion shall be presumed to be a scientifically valid	1673
and accurate description of the state of medical knowledge at the	1674
time it was written.	1675

Consistent with the Rules of Evidence, any party to a civil	1676
action related to a plan's decision involving an investigational	1677
or experimental drug, device, or treatment may introduce into	1678
evidence any applicable medicare reimbursement standards	1679
established under Title XVIII of the "Social Security Act," 49	1680
Stat. 620 (1935), 42 U.S.C.A. 301, as amended.	1681

Sec. 3922.21.  (A) When a record containing information	1682
pertaining to the medical history, diagnosis, prognosis, or	1683
medical condition of a covered person is provided to the	1684
superintendent of insurance for any reason under this chapter or	1685
sections 1751.77 to 1751.87 of the Revised Code, regardless of the	1686
source, the superintendent shall maintain the confidentiality of	1687
the record. The record in the superintendent's possession is not a	1688
public record under section 149.43 of the Revised Code, except to	1689
the extent that information from the record is used in preparing	1690
reports under section 3922.17 of the Revised Code.	1691

(B) Notwithstanding division (A) of this section, the	1692
superintendent may share a record that is the subject of this	1693
section in connection with the investigation or prosecution of any	1694
illegal or criminal activity with the chief deputy rehabilitator,	1695
the chief deputy liquidator, other deputy rehabilitators and	1696
liquidators, and any other person employed by, or acting on behalf	1697
of, the superintendent pursuant to Chapter 3901. or 3903. of the	1698
Revised Code, with other local, state, federal, and international	1699
regulatory and law enforcement agencies, with local, state, and	1700
federal prosecutors, and with the national association of	1701
insurance commissioners and its affiliates and subsidiaries,	1702
provided that the recipient agrees to maintain the confidential or	1703
privileged status of the confidential or privileged record and has	1704
authority to do so.	1705

(C) Nothing in this section shall prohibit the superintendent	1706
from receiving records in accordance with section 3901.045 of the	1707
Revised Code.	1708

(D) The superintendent may enter into agreements governing	1709
the sharing and use of records consistent with the requirements of	1710
this section.	1711

(E) No waiver of any applicable privilege or claim of	1712
confidentiality in the records that are the subject of this	1713
section shall occur as a result of sharing or receiving records as	1714
authorized in divisions (B) and (C) of this section.	1715

Sec. 3922.22.  The superintendent may adopt rules under	1716
Chapter 119. of the Revised Code to carry out the purposes of this	1717
chapter and shall prescribe forms relating to notices, appeals,	1718
and requests for external review under this chapter.	1719

Sec. 3922.23.  A violation of this chapter shall be an unfair	1720
or deceptive act or practice under sections 3901.19 to 3901.26 of	1721
the Revised Code. Additionally, health plan issuers holding a	1722
certificate of authority from the superintendent are also subject	1723
to the following:	1724

(A) If, after notice and hearing, the superintendent of	1725
insurance finds that a health plan issuer has failed to comply	1726
with the requirements of this chapter, the superintendent may	1727
suspend or revoke the health plan issuer's license to transact	1728
business within the state.	1729

(B)(1) In lieu of the suspension or revocation of a license	1730
under division (A) of this section, the superintendent of	1731
insurance, pursuant to an adjudication hearing initiated and	1732
conducted in accordance with Chapter 119. of the Revised Code, or	1733
by consent of the health plan issuer without an adjudication	1734
hearing, may levy an administrative penalty. The administrative	1735
penalty shall be in an amount determined by the superintendent,	1736
but the administrative penalty shall not exceed one hundred	1737
thousand dollars per violation. Additionally, the superintendent	1738
may require the health plan issuer to correct any deficiency that	1739
may be the basis for the suspension or revocation of the health	1740
plan issuer's license. All penalties collected shall be paid into	1741
the state treasury to the credit of the department of insurance	1742
operating fund.	1743

(2) If the superintendent for any reason has cause to believe	1744
that any violation of the requirements of this chapter has	1745
occurred or is threatened, the superintendent may give notice to	1746
the health plan issuer and to the representatives or other persons	1747
who appear to be involved in the suspected violation to arrange a	1748
conference with the suspected violators or their authorized	1749
representatives for the purpose of attempting to ascertain the	1750
facts relating to the suspected violation, and, if it appears that	1751
any violation has occurred or is threatened, to arrive at an	1752
adequate and effective means of correcting or preventing the	1753
violation.	1754

Proceedings shall not be covered by any formal procedural	1755
requirements, and may be conducted in the manner the	1756
superintendent may consider appropriate under the circumstances.	1757

(3)(a) The superintendent may issue an order directing a	1758
health plan issuer or a representative of the issuer to cease and	1759
desist from engaging in any act or practice in violation of the	1760
requirements of this chapter. Within thirty days after service of	1761
the order to cease and desist, the respondent may request a	1762
hearing on the question of whether acts or practices in violation	1763
of those sections have occurred. Such hearings shall be conducted	1764
in accordance with Chapter 119. of the Revised Code and judicial	1765
review shall be available as provided by that chapter.	1766

(b) If the superintendent has reasonable cause to believe	1767
that an order has been violated in whole or in part, the	1768
superintendent may request the attorney general to commence and	1769
prosecute any appropriate action or proceeding in the name of the	1770
state against the violators in the court of common pleas of	1771
Franklin county. The court in any such action or proceeding may	1772
levy civil penalties, not to exceed one hundred thousand dollars	1773
per violation, in addition to any other appropriate relief,	1774
including requiring a violator to pay the expenses reasonably	1775
incurred by the superintendent in enforcing the order. The	1776
penalties and fees collected shall be paid into the state treasury	1777
to the credit of the department of insurance operating fund.	1778

Sec. 3923.60.  (A) Notwithstanding section 3901.71 of the	1779
Revised Code, no group or individual policy of sickness and	1780
accident insurance that provides coverage for prescription drugs	1781
shall limit or exclude coverage for any drug approved by the	1782
United States food and drug administration on the basis that the	1783
drug has not been approved by the United States food and drug	1784
administration for the treatment of the particular indication for	1785
which the drug has been prescribed, provided the drug has been	1786
recognized as safe and effective for treatment of that indication	1787
in one or more of the standard medical reference compendia	1788
specified in division (B)(1) of this sectionadopted by the United	1789
States department of health and human services under 42 U.S.C.	1790
1395x(t)(2), as amended, or in medical literature that meets the	1791
criteria specified in division (B)(2) of this section.	1792

(B)(1) The compendia accepted for purposes of division (A) of	1793
this section are the following:	1794

(a) The "AMA drug evaluations," a publication of the American	1795
medical association;	1796

(b) The "AHFS (American hospital formulary service) drug	1797
information," a publication of the American society of health	1798
system pharmacists;	1799

(c) "Drug information for the health care provider," a	1800
publication of the United States pharmacopeia convention.	1801

(2) Medical literature may be accepted for purposes of	1802
division (A) of this section only if all of the following apply:	1803

(a)(1) Two articles from major peer-reviewed professional	1804
medical journals have recognized, based on scientific or medical	1805
criteria, the drug's safety and effectiveness for treatment of the	1806
indication for which it has been prescribed;	1807

(b)(2) No article from a major peer-reviewed professional	1808
medical journal has concluded, based on scientific or medical	1809
criteria, that the drug is unsafe or ineffective or that the	1810
drug's safety and effectiveness cannot be determined for the	1811
treatment of the indication for which it has been prescribed;	1812

(c)(3) Each article meets the uniform requirements for	1813
manuscripts submitted to biomedical journals established by the	1814
international committee of medical journal editors or is published	1815
in a journal specified by the United States department of health	1816
and human services pursuant to section 1861(t)(2)(B) of the	1817
"Social Security Act," 107 Stat. 591 (1993), 42 U.S.C.	1818
1395x(t)(2)(B), as amended, as acceptable peer-reviewed medical	1819
literature.	1820

(C) Coverage of a drug required by division (A) of this	1821
section includes medically necessary services associated with the	1822
administration of the drug.	1823

(D) Division (A) of this section shall not be construed to do	1824
any of the following:	1825

(1) Require coverage for any drug if the United States food	1826
and drug administration has determined its use to be	1827
contraindicated for the treatment of the particular indication for	1828
which the drug has been prescribed;	1829

(2) Require coverage for experimental drugs not approved for	1830
any indication by the United States food and drug administration;	1831

(3) Alter any law with regard to provisions limiting the	1832
coverage of drugs that have not been approved by the United States	1833
food and drug administration;	1834

(4) Require reimbursement or coverage for any drug not	1835
included in the drug formulary or list of covered drugs specified	1836
in a policy of sickness and accident insurance;	1837

(5) Prohibit a policy of sickness and accident insurance from	1838
limiting or excluding coverage of a drug, provided that the	1839
decision to limit or exclude coverage of the drug is not based	1840
primarily on the coverage of drugs required by this section.	1841

(E) This section, as amended, applies only to policies of	1842
sickness and accident insurance that are described in division (A)	1843
of this section and that are delivered, issued for delivery, or	1844
renewed in this state on or after the effective date of this	1845
amendment.	1846

Sec. 4731.36.  (A) Sections 4731.01 to 4731.47 of the Revised	1847
Code shall not prohibit service in case of emergency, domestic	1848
administration of family remedies, or provision of assistance to	1849
another individual who is self-administering drugs.	1850

Sections 4731.01 to 4731.47 of the Revised Code shall not	1851
apply to any of the following:	1852

(1) A commissioned medical officer of the United States armed	1853
forces, as defined in section 5903.11 of the Revised Code, or an	1854
employee of the veterans administration of the United States or	1855
the United States public health service in the discharge of the	1856
officer's or employee's professional duties;	1857

(2) A dentist authorized under Chapter 4715. of the Revised	1858
Code to practice dentistry when engaged exclusively in the	1859
practice of dentistry or when administering anesthetics in the	1860
practice of dentistry;	1861

(3) A physician or surgeon in another state or territory who	1862
is a legal practitioner of medicine or surgery therein when	1863
providing consultation to an individual holding a certificate to	1864
practice issued under this chapter who is responsible for the	1865
examination, diagnosis, and treatment of the patient who is the	1866
subject of the consultation, if one of the following applies:	1867

(a) The physician or surgeon does not provide consultation in	1868
this state on a regular or frequent basis.	1869

(b) The physician or surgeon provides the consultation	1870
without compensation of any kind, direct or indirect, for the	1871
consultation.	1872

(c) The consultation is part of the curriculum of a medical	1873
school or osteopathic medical school of this state or a program	1874
described in division (A)(2) of section 4731.291 of the Revised	1875
Code.	1876

(4) A physician or surgeon in another state or territory who	1877
is a legal practitioner of medicine or surgery therein and	1878
provided services to a patient in that state or territory, when	1879
providing, not later than one year after the last date services	1880
were provided in another state or territory, follow-up services in	1881
person or through the use of any communication, including oral,	1882
written, or electronic communication, in this state to the patient	1883
for the same condition;	1884

(5) A physician or surgeon residing on the border of a	1885
contiguous state and authorized under the laws thereof to practice	1886
medicine and surgery therein, whose practice extends within the	1887
limits of this state. Such practitioner shall not either in person	1888
or through the use of any communication, including oral, written,	1889
or electronic communication, open an office or appoint a place to	1890
see patients or receive calls within the limits of this state.	1891

(6) A board, committee, or corporation engaged in the conduct	1892
described in division (A) of section 2305.251 of the Revised Code	1893
when acting within the scope of the functions of the board,	1894
committee, or corporation;	1895

(7) The conduct of an independent review organization	1896
accredited by the superintendent of insurance under section	1897
3901.803922.13 of the Revised Code for the purpose of external	1898
reviews conducted under sections 1751.84, 1751.85, 3923.67,	1899
3923.68, 3923.76, and 3923.77Chapter 3922. of the Revised Code.	1900

(B) Sections 4731.51 to 4731.61 of the Revised Code do not	1901
apply to any graduate of a podiatric school or college while	1902
performing those acts that may be prescribed by or incidental to	1903
participation in an accredited podiatric internship, residency, or	1904
fellowship program situated in this state approved by the state	1905
medical board.	1906

(C) This chapter does not apply to an acupuncturist who	1907
complies with Chapter 4762. of the Revised Code.	1908

(D) This chapter does not prohibit the administration of	1909
drugs by any of the following:	1910

(1) An individual who is licensed or otherwise specifically	1911
authorized by the Revised Code to administer drugs;	1912

(2) An individual who is not licensed or otherwise	1913
specifically authorized by the Revised Code to administer drugs,	1914
but is acting pursuant to the rules for delegation of medical	1915
tasks adopted under section 4731.053 of the Revised Code;	1916

(3) An individual specifically authorized to administer drugs	1917
pursuant to a rule adopted under the Revised Code that is in	1918
effect on the effective date of this amendment, as long as the	1919
rule remains in effect, specifically authorizing an individual to	1920
administer drugs.	1921

(E) The exemptions described in divisions (A)(3), (4), and	1922
(5) of this section do not apply to a physician or surgeon whose	1923
certificate to practice issued under this chapter is under	1924
suspension or has been revoked or permanently revoked by action of	1925
the state medical board.	1926

Section 2. That existing sections 1751.11, 1751.33, 1751.35,	1927
1751.66, 1751.77, 1751.78, 1751.811, 1751.83, 1751.87, 1751.89,	1928
3901.045, 3923.60, and 4731.36 and sections 1751.831, 1751.84,	1929
1751.85, 1751.88, 3901.80, 3901.81, 3901.82, 3901.83, 3901.84,	1930
3923.66, 3923.67, 3923.68, 3923.681, 3923.69, 3923.70, 3923.75,	1931
3923.76, 3923.77, 3923.78, and 3923.79 of the Revised Code are	1932
hereby repealed.	1933

Section 3. This act, other than the amendments to sections	1934
1751.66 and 3923.60 of the Revised Code, shall apply to health	1935
benefit plans, as defined in section 3922.01 of the Revised Code	1936
as enacted in this act, in effect and under which requests for	1937
external review of adverse benefit determinations are submitted on	1938
or after January 1, 2012.	1939