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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 |
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 | 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 | 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 | 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 | 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) | 249 |
(B) | 250 |
251 |
| 252 |
253 |
| 254 |
255 | |
256 |
| 257 |
258 |
| 259 |
division (A) of this section only if all of the following apply: | 260 |
| 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 |
| 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 |
| 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 | 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 | 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
| 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 |
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
| 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 | 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 | 449 |
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 | 453 |
external review under | 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 | 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
| 466 |
Code | 467 |
468 | |
469 | |
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 | 477 |
of the Revised Code shall be construed to create a cause of action | 478 |
against | 479 |
| 480 |
employees through a health insuring corporation | 481 |
| 482 |
483 | |
484 |
| 485 |
486 | |
487 |
Sec. 1751.89. Sections 1751.77 to | 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, | 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 |
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) | 1792 |
(B) | 1793 |
1794 |
| 1795 |
1796 |
| 1797 |
1798 | |
1799 |
| 1800 |
1801 |
| 1802 |
division (A) of this section only if all of the following apply: | 1803 |
| 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 |
| 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 |
| 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 |
1898 | |
reviews conducted under
| 1899 |
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 |