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|
As Introduced
122nd General Assembly
Regular Session
1997-1998 | H. B. No. 361 |
REPRESENTATIVES VAN VYVEN-TAVARES-BENDER-BOYD-BRADING-CAREY-
CLANCY-CORBIN-COUGHLIN-FORD-GARCIA-GERBERRY-HOTTINGER-KRUPINSKI-
LAWRENCE-MAIER-MILLER-MOTTLEY-O'BRIEN-OLMAN-OPFER-
PADGETT-PERZ-SALERNO-SAWYER-SCHULER-SCHURING-STAPLETON-
TAYLOR-TERWILLEGER-TIBERI-VESPER-WACHTMANN-WISE-ROMAN
A BILL
To enact sections 1753.01, 1753.03, 1753.04, 1753.06, 1753.09,
1753.11 to 1753.13, 1753.15, 1753.21, 1753.22, 1753.24, 1753.26,
1753.28, 1753.30, 1753.36, 1753.38 to 1753.40,
1753.43, 1753.44, 1753.46 to
1753.49, 1753.51, 1753.66 to 1753.73, 1753.75,
and 1753.81 of the Revised
Code to adopt the Physician-Health Plan Partnership
Act.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That sections 1753.01, 1753.03, 1753.04, 1753.06,
1753.09, 1753.11, 1753.12, 1753.13, 1753.15, 1753.21,
1753.22, 1753.24, 1753.26, 1753.28, 1753.30, 1753.36,
1753.38, 1753.39, 1753.40, 1753.43, 1753.44, 1753.46, 1753.47, 1753.48,
1753.49, 1753.51, 1753.66, 1753.67, 1753.68, 1753.69, 1753.70, 1753.71,
1753.72,
1753.73, 1753.75, and 1753.81 of the Revised Code be
enacted to read as follows:
Sec. 1753.01. AS USED IN SECTIONS 1753.01 TO 1753.51 AND
1753.81 OF THE REVISED
CODE:
(A) "HEALTH CARE PLAN"
MEANS A CORPORATION THAT, PURSUANT TO A POLICY, CONTRACT,
CERTIFICATE, OR AGREEMENT, PAYS FOR, REIMBURSES, OR PROVIDES,
DELIVERS, ARRANGES FOR, OR OTHERWISE MAKES AVAILABLE, MEDICAL
TREATMENT OR OTHER HEALTH CARE SERVICES BY A PHYSICIAN OR OTHER
HEALTH CARE PROVIDER THROUGH EITHER AN OPEN PANEL PLAN OR A
CLOSED PANEL PLAN, IN EXCHANGE FOR A PREMIUM RATE.
(B) "PHYSICIAN" MEANS
ANY PERSON AUTHORIZED UNDER
CHAPTER 4731. OF THE
REVISED
CODE TO PRACTICE MEDICINE AND
SURGERY OR OSTEOPATHIC MEDICINE AND SURGERY.
Sec. 1753.03. THE SUPERINTENDENT OF INSURANCE SHALL, IN
RULES ADOPTED BY THE SUPERINTENDENT IN ACCORDANCE WITH
CHAPTER 119. OF THE
REVISED
CODE, PRESCRIBE A STANDARD
CREDENTIALING FORM TO BE USED BY ALL HEALTH CARE PLANS WHEN
CREDENTIALING PHYSICIANS. IN DEVELOPING THAT FORM, THE SUPERINTENDENT SHALL
TAKE INTO CONSIDERATION THE STANDARD CREDENTIALING FORMS DEVELOPED BY THE
NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS, THE AMERICAN MEDICAL
ASSOCIATION, THE AMERICAN ASSOCIATION OF HEALTH PLANS, AND ANY OTHER
NATIONAL ORGANIZATION THAT HAS DEVELOPED SUCH A FORM.
Sec. 1753.04. BEGINNING NINETY DAYS AFTER RULES ADOPTED
UNDER SECTION 1753.03 OF THE
REVISED
CODE TAKE EFFECT, NO HEALTH
CARE PLAN SHALL FAIL TO USE THE STANDARD CREDENTIALING FORM
PRESCRIBED IN THOSE RULES OR IN ANY AMENDMENT TO THOSE
RULES WHEN INITIALLY CREDENTIALING OR RECREDENTIALING PHYSICIANS.
A HEALTH CARE PLAN MAY REQUEST ADDITIONAL INFORMATION FROM
A PHYSICIAN AS NECESSARY TO COMPLY WITH THE PLAN'S CREDENTIALING
STANDARDS.
Sec. 1753.06. (A) AS
USED IN THIS SECTION:
(1) "ECONOMIC PROFILING" MEANS THE USE OF ECONOMIC
PERFORMANCE DATA AND ECONOMIC INFORMATION IN DETERMINING A
PHYSICIAN'S QUALIFICATION TO PARTICIPATE IN A HEALTH CARE
PLAN.
(2) "GROUP OF HEALTH CARE PROVIDERS" MEANS AN
ORGANIZATION, PARTNERSHIP, OR OTHER ASSOCIATION OF TWO OR MORE
PHYSICIANS OR OTHER LICENSED HEALTH CARE PROVIDERS THAT HAS
CONTRACTED TO PROVIDE HEALTH CARE SERVICES TO ENROLLEES OF A
HEALTH CARE PLAN, EITHER DIRECTLY WITH THE PLAN OR INDIRECTLY
THROUGH A GROUP OF HEALTH CARE PROVIDERS.
(B) A HEALTH CARE PLAN
OR GROUP OF HEALTH CARE PROVIDERS MAY USE ECONOMIC PROFILING AS
A FACTOR IN CREDENTIALING A PHYSICIAN ONLY IF THE ECONOMIC
PROFILING TAKES INTO CONSIDERATION THE CASE MIX, SEVERITY OF
ILLNESS, AND AGE OF PATIENTS.
(C) FOR AN INITIAL
APPLICANT, A HEALTH CARE PLAN MAY REQUEST INFORMATION NECESSARY
TO PERFORM AN ECONOMIC PROFILE. IF A PHYSICIAN DOES NOT PROVIDE
INFORMATION REQUESTED BY THE HEALTH CARE PLAN OR GROUP OF HEALTH
CARE PROVIDERS THAT ENABLES IT TO TAKE INTO CONSIDERATION CASE
MIX, SEVERITY OF ILLNESS, AND AGE OF PATIENTS, THE PLAN IS NOT
REQUIRED TO TAKE THESE FACTORS INTO CONSIDERATION IN ITS
ECONOMIC PROFILE OF THE PHYSICIAN.
(D) NOTHING IN THIS
SECTION PROHIBITS A HEALTH CARE PLAN OR GROUP OF HEALTH CARE
PROVIDERS FROM TAKING INTO CONSIDERATION THE QUALITY AND
APPROPRIATENESS OF CARE PROVIDED BY A PHYSICIAN WHEN DECIDING
WHETHER TO EMPLOY, CONTRACT WITH, OR TERMINATE THE
PHYSICIAN.
Sec. 1753.09. A HEALTH CARE PLAN SHALL NOTIFY A PHYSICIAN
OF THE STATUS OF THE PHYSICIAN'S APPLICATION WITHIN ONE HUNDRED
TWENTY DAYS AFTER THE PLAN'S RECEIPT OF THE COMPLETED
APPLICATION. THAT TIME PERIOD MAY BE EXTENDED BY THE PLAN IF,
DUE TO EXTENUATING CIRCUMSTANCES, THE PLAN NEEDS ADDITIONAL TIME
TO CONSIDER THE APPLICATION AND IT NOTIFIES THE PHYSICIAN OF THE
REASON FOR THE DELAY.
Sec. 1753.11. (A) PRIOR
TO ENTERING INTO A PARTICIPATION CONTRACT WITH A PHYSICIAN, A
HEALTH CARE PLAN SHALL, UPON REQUEST, DISCLOSE BASIC INFORMATION REGARDING ITS
PROGRAMS AND PROCEDURES TO THE PHYSICIAN. THE INFORMATION SHALL
INCLUDE ALL OF THE FOLLOWING:
(1) HOW A PHYSICIAN IS REIMBURSED FOR THE PHYSICIAN'S
SERVICES, AND THE AMOUNT OF THE REIMBURSEMENT;
(2) WHETHER ANY REINSURANCE PROTECTION IS PROVIDED OR IS
MADE AVAILABLE;
(3) WHETHER THE PLAN CHARGES ANY ADMINISTRATIVE,
OPERATIONS, OR MEMBERSHIP FEES, WHAT THE PURPOSE IS FOR THE
FEES, AND HOW FREQUENTLY THE FEES ARE COLLECTED;
(4) THE OUT-OF-POCKET COSTS FOR ENROLLEES, AND WHAT
PROCEDURES A PHYSICIAN MUST FOLLOW TO COLLECT THEM, IF
APPLICABLE;
(5) THE PROCEDURES THAT MUST BE FOLLOWED IN ORDER TO
SUBMIT A COMPLETED CLAIM, INCLUDING THE TIME WITHIN WHICH A
CLAIM MUST BE SUBMITTED;
(6) INFORMATION REGARDING QUALITY IMPROVEMENT PROGRAMS
AND ANY REQUIREMENTS IMPOSED ON PARTICIPATING PHYSICIANS;
(7) INFORMATION REGARDING UTILIZATION REVIEW PROGRAMS,
INCLUDING THE CRITERIA USED IN CONDUCTING UTILIZATION REVIEW,
THE RESOURCES USED TO DETERMINE THE APPROPRIATE UTILIZATION OF
SERVICES, THE PARTIES RESPONSIBLE FOR UTILIZATION REVIEW
DECISIONS, AND THE AVAILABILITY OF AN APPEAL PROCESS FOR ADVERSE
UTILIZATION REVIEW DECISIONS;
(8) ANY PENALTIES OR SANCTIONS FOR NONCOMPLIANCE WITH THE
PLAN'S HEALTH CARE SERVICE UTILIZATION PROTOCOLS OR
PROGRAMS;
(9) HOW REFERRALS TO OTHER PARTICIPATING PHYSICIANS OR TO
NONPARTICIPATING PHYSICIANS ARE MADE;
(10) WHETHER PHYSICIANS ARE REQUIRED TO BE AVAILABLE TO
ENROLLEES AT CERTAIN TIMES, AND ANY LIMITATIONS ON THE SELECTION
OF A PHYSICIAN TO TREAT ENROLLEES ON A PHYSICIAN'S BEHALF WHEN
THE PHYSICIAN IS UNAVAILABLE;
(11) THE AVAILABILITY OF DISPUTE RESOLUTION PROCEDURES
AND THE POTENTIAL FOR COST TO BE INCURRED;
(12) THE LEVELS OF PROFESSIONAL LIABILITY INSURANCE
REQUIRED FOR PARTICIPATING PHYSICIANS;
(13) HOW A PHYSICIAN'S NAME AND ADDRESS WILL BE USED IN
MARKETING MATERIALS;
(14) HOW A CONTRACT MAY BE AMENDED, WHETHER A PHYSICIAN
MAY OBJECT TO A CONTRACT AMENDMENT, WHETHER AMENDMENTS MAY BE
MADE TO DOCUMENTS INCORPORATED BY REFERENCE INTO THE CONTRACT,
AND WHETHER AN OPPORTUNITY TO OBJECT TO SUCH CHANGES WILL BE
GRANTED;
(15) UNDER WHAT CIRCUMSTANCES EITHER PARTY CAN TERMINATE
THE CONTRACT, WHAT OPPORTUNITY IS AFFORDED A PARTICIPATING
PHYSICIAN TO REQUEST RECONSIDERATION OF A TERMINATION DECISION,
AND WHAT OBLIGATIONS EXIST FOR A PHYSICIAN UPON
TERMINATION.
(B) A HEALTH CARE PLAN
SHALL PROVIDE ALL OF THE FOLLOWING TO A PARTICIPATING
PHYSICIAN:
(1) ANY MATERIAL INCORPORATED BY REFERENCE INTO THE
PARTICIPATION CONTRACT;
(2) ADMINISTRATIVE MANUALS RELATED TO PHYSICIAN
PARTICIPATION, IF ANY;
(3) A SIGNED AND DATED COPY OF THE FINAL PARTICIPATION
CONTRACT.
Sec. 1753.12. (A) A
HEALTH CARE PLAN SHALL NOTIFY A PHYSICIAN PRIOR TO AMENDING THE
PHYSICIAN'S PARTICIPATION CONTRACT WITH THE PLAN, OR AMENDING
ANY DOCUMENT INCORPORATED BY REFERENCE INTO THE CONTRACT, IF THE
AMENDMENT AFFECTS PARTICIPATING PHYSICIANS. SUCH AN AMENDMENT
IS NOT EFFECTIVE UNTIL A PHYSICIAN HAS HAD REASONABLE TIME, AS DEFINED IN THE
CONTRACT, TO EXERCISE THE PHYSICIAN'S RIGHT TO TERMINATE PARTICIPATION STATUS
IN ACCORDANCE WITH THE TERMS AND CONDITIONS OF THE
CONTRACT.
(B) DIVISION
(A) OF THIS SECTION DOES NOT
APPLY IF THE DELAY CAUSED BY COMPLIANCE WITH THAT DIVISION COULD
RESULT IN IMMINENT HARM TO AN ENROLLEE OR IF THE AMENDMENT IS
REQUIRED BY STATE OR FEDERAL LAW, RULE, OR REGULATION.
Sec. 1753.13. (A) NO
HEALTH CARE PLAN OR ANY OF ITS CONTRACTING ENTITIES SHALL
INCLUDE, IN ANY CONTRACT ENTERED INTO WITH A PHYSICIAN, ANY
PROVISION THAT LIMITS OR OTHERWISE RESTRICTS THE PHYSICIAN'S
ETHICAL AND LEGAL RESPONSIBILITY TO FULLY ADVISE PATIENTS ABOUT
THEIR MEDICAL CONDITION AND THE MEDICALLY APPROPRIATE TREATMENT
OPTIONS.
(B) NO HEALTH CARE PLAN
SHALL TERMINATE EMPLOYMENT OR ANY OTHER CONTRACTUAL RELATIONSHIP
WITH, OR OTHERWISE PENALIZE, A PHYSICIAN PRINCIPALLY FOR
ADVOCATING FOR MEDICALLY APPROPRIATE HEALTH CARE.
(C) THIS SECTION SHALL
NOT BE CONSTRUED AS PROHIBITING A HEALTH CARE PLAN FROM DOING
EITHER OF THE FOLLOWING:
(1) MAKING A DETERMINATION NOT TO REIMBURSE OR PAY FOR A
PARTICULAR MEDICAL TREATMENT OR OTHER HEALTH CARE
SERVICE;
(2) ENFORCING REASONABLE PEER REVIEW OR UTILIZATION
REVIEW PROTOCOLS, OR DETERMINING WHETHER A PHYSICIAN HAS
COMPLIED WITH THOSE PROTOCOLS.
Sec. 1753.15. (A) EXCEPT AS PROVIDED IN DIVISION (D) OF
THIS SECTION, PRIOR TO TERMINATING A CONTRACT WITH A PHYSICIAN ON THE BASIS OF
THE
PHYSICIAN'S DELIVERY OF HEALTH CARE SERVICES, A HEALTH CARE PLAN
SHALL GIVE THE PHYSICIAN NOTICE OF THE REASON OR REASONS FOR ITS
DECISION TO TERMINATE AND AN OPPORTUNITY TO TAKE CORRECTIVE
ACTION. THE PLAN SHALL DEVELOP A CORRECTIVE ACTION PLAN IN
CONJUNCTION WITH THE PHYSICIAN. IF, AFTER BEING AFFORDED THE
OPPORTUNITY TO TAKE CORRECTIVE ACTION, THE PHYSICIAN FAILS TO DO
SO, THE PLAN MAY TERMINATE THE CONTRACT.
(B)(1) A PHYSICIAN WHOSE
CONTRACT HAS BEEN TERMINATED UNDER DIVISION
(A) OF THIS SECTION MAY APPEAL
THE TERMINATION TO THE APPROPRIATE MEDICAL DIRECTOR OF THE PLAN. THE
MEDICAL DIRECTOR SHALL GIVE THE PHYSICIAN AN OPPORTUNITY TO
DISCUSS WITH THE MEDICAL DIRECTOR THE REASON OR REASONS FOR THE
TERMINATION.
(2) IF A SATISFACTORY RESOLUTION CANNOT BE REACHED, THE
PHYSICIAN MAY APPEAL THE TERMINATION DECISION TO A PANEL
COMPOSED OF PHYSICIANS WHO ARE UNDER CONTRACT WITH THE HEALTH
CARE PLAN AND WHO HAVE COMPARABLE OR HIGHER LEVELS OF EDUCATION
AND TRAINING THAN THE PHYSICIAN. A REPRESENTATIVE OF THE
PHYSICIAN'S SPECIALTY SHALL BE A MEMBER OF THE PANEL, IF
POSSIBLE.
THE PANEL SHALL RENDER ITS DECISION TO THE PHYSICIAN AND
TO THE MEDICAL DIRECTOR WITHIN THIRTY DAYS AFTER HOLDING A
HEARING ON THE MATTER.
(3) THE MEDICAL DIRECTOR SHALL REVIEW AND CONSIDER THE
PANEL'S DETERMINATION BEFORE MAKING A DECISION. THE DECISION
RENDERED BY THE MEDICAL DIRECTOR IS FINAL.
(C) A PHYSICIAN'S
CONTRACT SHALL REMAIN IN EFFECT DURING THE APPEAL PROCESS SET
FORTH IN DIVISION (B) OF THIS
SECTION UNLESS THE TERMINATION WAS BASED ON ANY OF THE REASONS
LISTED IN DIVISION (D) OF THIS
SECTION.
(D) NOTWITHSTANDING DIVISION (A) OF THIS SECTION, A
PHYSICIAN'S CONTRACT MAY BE TERMINATED AT ANY TIME WITHOUT NOTICE IF
EVIDENCE EXISTS OF IMMINENT RISK OF HARM TO AN ENROLLEE OR ENROLLEES BASED
UPON A FINDING OF UNACCEPTABLE QUALITY OF CARE, FRAUD, PATIENT
ABUSE, LOSS OF CLINICAL PRIVILEGES, LOSS OF PROFESSIONAL
LIABILITY COVERAGE IF THE CONTRACT REQUIRES SUCH COVERAGE,
INCOMPETENCE, LOSS OF AUTHORITY TO PRACTICE MEDICINE AND
SURGERY OR OSTEOPATHIC MEDICINE AND SURGERY UNDER
CHAPTER 4731. OF THE REVISED CODE, OR A
GOVERNMENTAL ACTION HAS IMPAIRED THE PHYSICIAN'S ABILITY TO PRACTICE.
(E)(1) NOTHING IN THIS
SECTION PROHIBITS A HEALTH CARE PLAN OR GROUP OF HEALTH CARE
PROVIDERS FROM REJECTING A PHYSICIAN'S APPLICATION FOR
PARTICIPATION ON A PANEL, OR TERMINATING A PHYSICIAN'S
PARTICIPATION ON A PANEL, IF THE PLAN DETERMINES THAT THE PLAN
IS MEETING THE HEALTH CARE NEEDS OF ITS ENROLLEES AND NO
ADDITIONAL NEED EXISTS IN ITS PROVIDER NETWORK FOR THE
PHYSICIAN'S SERVICES.
(2) NOTHING IN THIS SECTION REQUIRES A HEALTH CARE PLAN
OR A GROUP OF HEALTH CARE PROVIDERS TO EMPLOY OR CONTRACT WITH
ANY PARTICULAR CATEGORY OF HEALTH CARE PROVIDER OR HEALTH CARE
FACILITY.
Sec. 1753.21. (A) EACH
HEALTH CARE PLAN SHALL PROVIDE TO
ENROLLEES AND PURCHASERS AN
EVIDENCE OF COVERAGE THAT INCLUDES ALL OF THE FOLLOWING
INFORMATION:
(1) THE PLAN STRUCTURE;
(2) THE BENEFITS COVERED AND EXCLUDED BY THE PLAN;
(3) PROCEDURES GOVERNING OUT-OF-AREA COVERAGE;
(4) ENROLLEE COST-SHARING REQUIREMENTS;
(5) ANY PRIOR APPROVAL REQUIREMENTS FOR OBTAINING
PRESCRIPTION DRUGS;
(6) HOW AN ENROLLEE OBTAINS PREVENTIVE HEALTH SERVICES
AND HEALTH EDUCATION PROVIDED BY THE PLAN;
(7) HOW AN ENROLLEE OBTAINS MEDICALLY NECESSARY COVERAGE,
EMERGENCY CARE COVERAGE, OUT-OF-AREA EMERGENCY CARE, AND URGENT
CARE SERVICES;
(8) IF REQUIRED, HOW AN ENROLLEE SELECTS A PRIMARY CARE
PHYSICIAN, AND THE PROCESS BY WHICH AN ENROLLEE CHANGES THAT
SELECTION;
(9) THE PLAN'S UTILIZATION REVIEW PROCEDURES, INCLUDING
THE PROCEDURES FOR OBTAINING REVIEW OF ADVERSE DETERMINATIONS
AND A STATEMENT OF THE RIGHTS AND RESPONSIBILITIES OF ENROLLEES
WITH RESPECT TO THOSE PROCEDURES;
(10) THE REVIEW PROCEDURES USED TO DETERMINE COVERAGE OF
INVESTIGATIONAL OR EXPERIMENTAL TREATMENTS;
(11) IF APPLICABLE, PLAN UTILIZATION OF VOLUNTARY OR
MANDATORY ARBITRATION OR DISPUTE RESOLUTION PROCEDURES;
(12) HOW TO FILE A GRIEVANCE AGAINST THE PLAN;
(13) A STATEMENT THAT THE INFORMATION LISTED IN DIVISION (C) OF
THIS SECTION IS AVAILABLE FROM THE PLAN UPON REQUEST.
(B) A HEALTH CARE PLAN SHALL, UPON REQUEST, PROVIDE TO A
PROSPECTIVE ENROLLEE OR PROSPECTIVE PURCHASER A SUMMARY OF ANY OF THE
INFORMATION INCLUDED IN THE PLAN'S EVIDENCE OF COVERAGE. THE SUMMARY SHALL
INCLUDE A STATEMENT THAT THE INFORMATION LISTED IN DIVISION (C) OF
THIS SECTION IS AVAILABLE FROM THE PLAN UPON REQUEST.
(C) A HEALTH CARE PLAN
SHALL, UPON REQUEST, PROVIDE TO A PROSPECTIVE ENROLLEE,
PROSPECTIVE PURCHASER, ENROLLEE, OR PURCHASER ANY OF THE
FOLLOWING INFORMATION:
(1) THE QUALITY AND SATISFACTION ASSESSMENTS USED BY THE
PLAN, INCLUDING THE CURRENT RESULTS OF THE ASSESSMENTS;
(2) A DESCRIPTION OF THE PLAN'S QUALITY IMPROVEMENT
PROGRAM;
(3) IF APPLICABLE, INFORMATION ON LOCATIONS AND HOURS OF
OPERATION OF THE MEDICAL OFFICES, HOSPITALS, AND ALL OTHER
FACILITIES OWNED BY THE PLAN AT WHICH THE ENROLLEE CAN OBTAIN
COVERED HEALTH CARE SERVICES;
(4) A DESCRIPTION OF THE TYPE OF FINANCIAL RISK ARRANGEMENTS, INCLUDING
BUT NOT LIMITED TO CAPITATION, FINANCIAL INCENTIVES OR BONUSES,
FEE-FOR-SERVICE, SALARY, AND WITHHOLDINGS, UNDER WHICH THE
PLAN'S PHYSICIANS PROVIDE HEALTH CARE SERVICES. NOTHING IN DIVISION
(C)(4) OF THIS SECTION SHALL BE
CONSTRUED AS REQUIRING HEALTH CARE PLANS TO DISCLOSE PROPRIETARY
INFORMATION, INCLUDING, BUT NOT LIMITED TO, REIMBURSEMENT AMOUNTS
TO INDIVIDUAL PROVIDERS OR FACILITIES.
(5) THE CURRENT LIST OF THE PLAN'S PARTICIPATING
PROVIDERS WITHIN THE ENROLLEE'S GEOGRAPHIC SERVICE AREA. THE
LIST SHALL INCLUDE AT LEAST THE FOLLOWING INFORMATION FOR EACH SUCH
PROVIDER:
(a) THE DEGREE OBTAINED;
(b) THE PRACTICE SPECIALTY;
(c) PRACTICE LOCATION, INCLUDING ADDRESS AND
TELEPHONE NUMBER.
(6) INFORMATION REGARDING FORMULARY INCLUSION OR
EXCLUSION OF A PARTICULAR DRUG OR THERAPEUTIC CLASS OF
DRUGS;
(7) A LOCAL OR TOLL-FREE TELEPHONE NUMBER TO CALL TO
OBTAIN ADDITIONAL INFORMATION ABOUT THE PLAN AND ITS
OPERATIONS.
(D) ALL OF THE
INFORMATION DISCLOSED BY A HEALTH CARE PLAN PURSUANT TO THIS
SECTION SHALL BE ACCURATE AND CURRENT, AND SHALL BE PROVIDED IN
A MANNER THAT MEETS THE READABILITY REQUIREMENT SET FORTH IN DIVISION
(A)(1) OF SECTION 3902.04 of the Revised Code.
Sec. 1753.22. EACH HEALTH CARE PLAN SHALL ESTABLISH A
SYSTEM THAT ENABLES AN ENROLLEE'S ELIGIBILITY TO RECEIVE COVERED
HEALTH CARE SERVICES FROM A PHYSICIAN OR HEALTH CARE FACILITY,
AND THE PARTICIPATING STATUS OF A PHYSICIAN OR FACILITY, TO BE
VERIFIED AT ANY TIME THE PHYSICIAN OR FACILITY IS OBLIGATED TO
PROVIDE OR ARRANGE FOR THE PROVISION OF COVERED HEALTH CARE
SERVICES, INCLUDING TIMES OTHER THAN DURING THE PLAN'S NORMAL
BUSINESS HOURS.
Sec. 1753.24. (A) A HEALTH CARE
PLAN SHALL ESTABLISH AND IMPLEMENT A PROCEDURE BY WHICH
AN ENROLLEE MAY RECEIVE A STANDING REFERRAL TO A SPECIALIST. THE PROCEDURE
SHALL PROVIDE FOR A STANDING REFERRAL TO
A SPECIALIST IF THE PRIMARY CARE PHYSICIAN DETERMINES IN CONSULTATION WITH
THE SPECIALIST, IF ANY, THAT AN
ENROLLEE NEEDS CONTINUING CARE FROM A SPECIALIST. THE
REFERRAL SHALL BE MADE PURSUANT TO A TREATMENT PLAN APPROVED BY
THE PLAN IN CONSULTATION WITH THE PRIMARY CARE
PHYSICIAN, THE SPECIALIST, AND THE ENROLLEE. THE TREATMENT PLAN MAY
LIMIT THE NUMBER OF VISITS TO THE SPECIALIST, LIMIT THE PERIOD
OF TIME THAT THE VISITS ARE AUTHORIZED, OR REQUIRE THAT THE
SPECIALIST PROVIDE THE PRIMARY CARE PHYSICIAN WITH REGULAR
REPORTS ON THE HEALTH CARE PROVIDED TO THE ENROLLEE.
(B) A HEALTH CARE PLAN SHALL ESTABLISH AND
IMPLEMENT A PROCEDURE BY WHICH AN ENROLLEE WITH A CONDITION OR
DISEASE THAT REQUIRES SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME
AND IS LIFE-THREATENING, DEGENERATIVE, OR DISABLING MAY RECEIVE A
REFERRAL TO A SPECIALIST WHO HAS EXPERTISE IN TREATING THE
CONDITION OR DISEASE FOR THE PURPOSE OF HAVING THE SPECIALIST COORDINATE THE
ENROLLEE'S HEALTH CARE. THE REFERRAL
SHALL BE MADE PURSUANT TO A TREATMENT PLAN APPROVED
BY THE HEALTH CARE PLAN IN CONSULTATION WITH THE PRIMARY CARE
PHYSICIAN, SPECIALIST, AND ENROLLEE. AFTER THE REFERRAL IS
MADE, THE SPECIALIST SHALL BE
AUTHORIZED TO PROVIDE HEALTH CARE SERVICES TO THE ENROLLEE IN
THE SAME MANNER AS THE ENROLLEE'S PRIMARY CARE
PHYSICIAN, SUBJECT TO THE TERMS OF THE TREATMENT PLAN.
(C) THE DETERMINATIONS DESCRIBED IN DIVISIONS
(A) AND (B) OF THIS SECTION SHALL BE
MADE WITHIN SEVENTY-TWO HOURS AFTER A REQUEST FOR THE
DETERMINATION IS MADE BY THE ENROLLEE OR THE ENROLLEE'S PRIMARY
CARE PHYSICIAN AND ALL APPROPRIATE MEDICAL RECORDS AND OTHER ITEMS OF
INFORMATION NECESSARY TO MAKE THE DETERMINATION ARE PROVIDED. ONCE A
DETERMINATION IS MADE, THE
REFERRAL SHALL BE MADE WITHIN NINETY-SIX HOURS AFTER THE
DETERMINATION.
DIVISIONS (A) AND
(B) OF THIS SECTION DO NOT
REQUIRE A HEALTH CARE PLAN TO PERMIT AN ENROLLEE TO
ELECT REFERRAL TO A SPECIALIST WHO IS NOT EMPLOYED BY OR UNDER
CONTRACT WITH THE PLAN TO PROVIDE HEALTH CARE SERVICES TO ITS
ENROLLEES.
Sec. 1753.26. A HEALTH CARE PLAN OR UTILIZATION REVIEW ORGANIZATION THAT
AUTHORIZES A PROPOSED ADMISSION, TREATMENT, OR SERVICE BY A PHYSICIAN BASED
UPON THE TRUTHFUL SUBMISSION OF ALL NECESSARY INFORMATION RELATIVE TO AN
ELIGIBLE ENROLLEE SHALL NOT
RETROACTIVELY DENY THIS AUTHORIZATION IF THE PHYSICIAN RENDERS THE HEALTH CARE
SERVICE IN GOOD FAITH AND PURSUANT TO THE AUTHORIZATION AND ALL OF THE TERMS
AND CONDITIONS OF THE PHYSICIAN'S CONTRACT WITH THE PLAN.
Sec. 1753.28. EACH EXPLANATION OF BENEFITS STATEMENT SENT BY A HEALTH
CARE PLAN TO AN
ENROLLEE SHALL CONTAIN A
CLEAR EXPLANATION OF THE SERVICES RENDERED, THE AMOUNT PAID BY THE
PLAN, AND THE FINANCIAL OBLIGATIONS OF THE ENROLLEE, IF
ANY.
Sec. 1753.30. EACH HEALTH CARE PLAN SHALL NOTIFY AFFECTED ENROLLEES OF THE
TERMINATION OF ANY CONTRACT WITH A PRIMARY CARE PHYSICIAN OR HOSPITAL.
Sec. 1753.36. (A) IF A HEALTH CARE PLAN OR PHARMACY BENEFIT
MANAGEMENT PROVIDER IS USING A RESTRICTED FORMULARY OF PRESCRIPTION DRUG
PRODUCTS, THE HEALTH CARE PLAN SHALL DO BOTH OF THE FOLLOWING:
(1) DEVELOP SUCH A FORMULARY IN CONSULTATION WITH AND APPROVAL OF A
PHARMACY AND THERAPEUTICS COMMITTEE, A MAJORITY OF THE MEMBERS OF WHICH ARE
PARTICIPATING PHYSICIANS OF THE HEALTH CARE PLAN WHO MAY PRESCRIBE
PRESCRIPTION
DRUGS AND PARTICIPATING PHARMACISTS OF THE PLAN, OR IN CONSULTATION WITH AND
APPROVAL OF A PHARMACY AND THERAPEUTICS COMMITTEE OF A PHARMACY BENEFIT
MANAGEMENT PROVIDER THAT IS INDEPENDENT OF THE HEALTH CARE PLAN, CONSISTING OF
PHYSICIANS WHO MAY PRESCRIBE
PRESCRIPTION DRUGS IN THEIR STATE OF LICENSURE AND PHARMACISTS WHO ARE
AUTHORIZED TO PRACTICE IN THEIR STATE OF LICENSURE.
(2) ESTABLISH A PROCEDURE BY WHICH AN ENROLLEE MAY OBTAIN, WITHOUT PENALTY
OR ADDITIONAL COST SHARING BEYOND THAT PROVIDED FOR FORMULARY DRUGS UNDER
THE ENROLLEE'S CONTRACT WITH THE PLAN, COVERAGE OF A SPECIFIC NONFORMULARY
DRUG WHEN THE PRESCRIBER DOCUMENTS IN THE ENROLLEE'S MEDICAL RECORD AND
CERTIFIES THAT THE FORMULARY ALTERNATIVE HAS BEEN INEFFECTIVE IN THE TREATMENT
OF THE ENROLLEE'S DISEASE OR CONDITION, OR THAT THE FORMULARY ALTERNATIVE
CAUSES OR IS REASONABLY EXPECTED BY THE PRESCRIBER TO CAUSE A HARMFUL OR
ADVERSE REACTION IN THE ENROLLEE.
(B) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE A
HEALTH CARE PLAN TO PLACE ANY PARTICULAR PHARMACEUTICAL PRODUCT OR THERAPEUTIC
CLASS OF PRODUCT ON ITS FORMULARY, OR TO PROHIBIT A HEALTH CARE PLAN FROM
RESTRICTING PAYMENT FOR ANY SPECIFIC PHARMACEUTICAL PRODUCT OR THERAPEUTIC
CLASS
OF PRODUCT, INCLUDING, BUT NOT LIMITED TO, BY REQUIRING THAT THE PRODUCT BE
PRESCRIBED ONLY BY A DEFINED SPECIALIST OR SUBSPECIALIST.
Sec. 1753.38. EACH HEALTH CARE PLAN SHALL ESTABLISH AN INTERNAL TECHNOLOGY
ASSESSMENT PROCESS FOR ASSESSING WHETHER A DRUG, DEVICE, PROCEDURE, OR OTHER
THERAPY IS PROVEN TO BE SAFE AND EFFICACIOUS FOR A PARTICULAR INDICATION OR
CONDITION WHEN COMPARED TO ALTERNATIVE THERAPIES, OR WHETHER IT REMAINS
EXPERIMENTAL OR INVESTIGATIONAL. THE PLAN'S INTERNAL TECHNOLOGY ASSESSMENT
PROCESS SHALL MEET ALL OF THE FOLLOWING CRITERIA:
(A) DECISIONS ARE MADE BY MEDICAL PROFESSIONALS, INCLUDING
PHYSICIANS.
(B) THE PROCESS INCLUDES A REVIEW OF RELEVANT MEDICAL EVIDENCE,
INCLUDING THE FOLLOWING, IF AVAILABLE:
(1) PEER-REVIEWED MEDICAL AND SCIENTIFIC LITERATURE ON THE SUBJECT;
(2) PUBLISHED OPINIONS, ACTIONS, AND OTHER RELEVANT DOCUMENTS OF
INDEPENDENT, EXTERNAL RESEARCH ORGANIZATIONS SUCH AS THE NATIONAL INSTITUTE OF
HEALTH, THE NATIONAL CANCER INSTITUTE, THE UNITED STATES
FOOD AND DRUG ADMINISTRATION, AND THE AGENCY FOR HEALTH CARE POLICY AND
RESEARCH;
(3) PUBLISHED OPINIONS OF MEDICAL EXPERTS OR AFFECTED SPECIALTY SOCIETIES.
(C) GENERAL COVERAGE DECISIONS, MADE PURSUANT TO THIS PROCESS,
THAT EXCLUDE DRUGS, DEVICES, PROCEDURES, OR OTHER THERAPIES ON THE BASIS THAT
THEY ARE NOT SAFE OR EFFICACIOUS AND REMAIN EXPERIMENTAL OR INVESTIGATIONAL
ARE REVIEWED AND UPDATED AS NEW SCIENTIFIC EVIDENCE BECOMES AVAILABLE.
(D) A DESCRIPTION OF THE PLAN'S INTERNAL TECHNOLOGY ASSESSMENT
PROCESS IS MADE AVAILABLE TO PARTICIPATING PROVIDERS AND ENROLLEES, UPON
REQUEST. THE PLAN ALSO MAKES AVAILABLE, TO PARTICIPATING PROVIDERS AND
ENROLLEES, UPON REQUEST, A COPY OF SPECIFIC COVERAGE POLICIES FOR SPECIFIC
CONDITIONS OR TREATMENTS IF SUCH POLICIES HAVE BEEN MADE PURSUANT TO THE
PROCESS REQUIRED BY THIS SECTION, WHEN THE ENROLLEE HAS BEEN DENIED COVERAGE
FOR THAT PARTICULAR CONDITION OR TREATMENT. SPECIFIC COVERAGE POLICIES SHALL
INCLUDE A DESCRIPTION OF THE EVIDENCE UPON WHICH THE POLICY WAS BASED, AND
SHALL CONTAIN THE DATE THE POLICY WAS ADOPTED.
(E) IF THE PLAN HAS NOT CONDUCTED A TECHNOLOGY ASSESSMENT FOR A
PROPOSED THERAPY FOR A PARTICULAR PATIENT'S MEDICAL CONDITION, AND THAT
THERAPY MAY BE CONSIDERED EXPERIMENTAL OR INVESTIGATIONAL, THE PLAN SHALL
CONDUCT A TECHNOLOGY ASSESSMENT OF THE PROPOSED THERAPY PURSUANT TO THIS
SECTION OR
USE THE EXTERNAL, INDEPENDENT REVIEW PROCESS REQUIRED IN SECTION 1753.39
of the Revised Code.
Sec. 1753.39. (A) EACH HEALTH CARE PLAN SHALL ESTABLISH A
REASONABLE EXTERNAL, INDEPENDENT REVIEW PROCESS TO EXAMINE THE PLAN'S COVERAGE
DECISIONS FOR INDIVIDUAL ENROLLEES WHO MEET ALL OF THE FOLLOWING CRITERIA:
(1) THE ENROLLEE HAS A TERMINAL CONDITION THAT, ACCORDING TO THE CURRENT
DIAGNOSIS OF THE ENROLLEE'S PHYSICIAN, HAS A HIGH PROBABILITY OF CAUSING
DEATH WITHIN TWO YEARS.
(2) THE ENROLLEE'S PHYSICIAN CERTIFIES THAT THE ENROLLEE HAS THE CONDITION
DESCRIBED IN DIVISION (A)(1) OF THIS SECTION, FOR WHICH
STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN IMPROVING THE CONDITION OF THE
ENROLLEE, OR FOR WHICH STANDARD THERAPIES WOULD NOT BE MEDICALLY APPROPRIATE
FOR THE ENROLLEE, OR FOR WHICH THERE IS NO MORE BENEFICIAL STANDARD THERAPY
COVERED BY THE PLAN THAN THE THERAPY DESCRIBED IN DIVISION (A)(3) OF
THIS SECTION.
(3) THE ENROLLEE'S PHYSICIAN HAS RECOMMENDED A DRUG, DEVICE, PROCEDURE, OR
OTHER THERAPY THAT THE PHYSICIAN CERTIFIES IN WRITING, IN THE PHYSICIAN'S
OPINION, IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE THAN STANDARD
THERAPIES, OR THE ENROLLEE HAS REQUESTED A THERAPY THAT HAS BEEN FOUND, IN A
PREPONDERANCE OF PEER-REVIEWED PUBLISHED STUDIES, TO BE ASSOCIATED WITH
EFFECTIVE CLINICAL OUTCOMES FOR THE SAME CONDITION.
(4) THE ENROLLEE HAS BEEN DENIED COVERAGE BY THE PLAN FOR A DRUG, DEVICE,
PROCEDURE, OR OTHER THERAPY RECOMMENDED OR REQUESTED PURSUANT TO DIVISION
(A)(3) OF THIS SECTION.
(5) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, RECOMMENDED PURSUANT TO
DIVISION (A)(3) OF THIS SECTION, WOULD BE A COVERED SERVICE EXCEPT
FOR THE PLAN'S DETERMINATION THAT THE DRUG, DEVICE, PROCEDURE, OR OTHER
THERAPY IS EXPERIMENTAL OR INVESTIGATIONAL.
(B) THE EXTERNAL, INDEPENDENT REVIEW PROCESS ESTABLISHED BY A
HEALTH CARE PLAN SHALL MEET ALL OF THE FOLLOWING CRITERIA:
(1) THE PLAN OFFERS ALL ENROLLEES WHO MEET THE CRITERIA SET FORTH IN
DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE THE REQUESTED
THERAPY REVIEWED UNDER THE EXTERNAL, INDEPENDENT REVIEW PROCESS, AND NOTIFIES
EACH ELIGIBLE ENROLLEE OF THAT OPPORTUNITY WITHIN FIVE BUSINESS DAYS AFTER THE
PLAN DECIDED TO DENY COVERAGE.
(2) THE PLAN CONTRACTS WITH ONE OR MORE IMPARTIAL, INDEPENDENT ENTITIES
ACCREDITED PURSUANT TO SECTION 1753.40 of the Revised Code, THAT ARRANGE FOR REVIEW OF THE
COVERAGE DECISION BY SELECTING A PANEL OF AT LEAST TWO PHYSICIANS OR OTHER
PROVIDERS WHO ARE EXPERTS IN THE TREATMENT OF THE ENROLLEE'S MEDICAL CONDITION
AND KNOWLEDGEABLE ABOUT THE RECOMMENDED THERAPY.
(3) NEITHER THE PLAN NOR THE ENROLLEE CHOOSES, OR CONTROLS THE CHOICE OF,
THE PHYSICIAN EXPERTS.
(4) NEITHER THE PHYSICIAN EXPERTS NOR THE ENTITY ARRANGING FOR THE
EXPERTS' OPINIONS HAVE ANY PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION
WITH THE PLAN, EXCEPT THAT EXPERTS AFFILIATED WITH ACADEMIC MEDICAL CENTERS
WHO PROVIDE SERVICES TO PLAN ENROLLEES MAY SERVE AS EXPERTS ON THE REVIEW
PANEL. THE REQUIREMENT OF DIVISION (B)(4) OF THIS SECTION DOES NOT
PRECLUDE A PLAN FROM PAYING FOR THE EXPERTS' OPINIONS, AS SPECIFIED IN
DIVISION (B)(5) OF THIS SECTION. THE EXPERTS SHALL HAVE NO
PATIENT-PHYSICIAN RELATIONSHIP OR OTHER AFFILIATION WITH THE ENROLLEE WHOSE
TREATMENT IS UNDER REVIEW OR WITH THE PROVIDER PROPOSING THE THERAPY.
(5) ENROLLEES ARE NOT REQUIRED TO PAY FOR THE EXTERNAL, INDEPENDENT
REVIEW. THE COSTS OF THE REVIEW ARE BORNE BY THE PLAN.
(6) THE PLAN PROVIDES TO THE INDEPENDENT ENTITY ARRANGING FOR THE EXPERTS'
OPINIONS AND TO THE ENROLLEE AND THE ENROLLEE'S PHYSICIAN A COPY OF THOSE
MEDICAL RECORDS IN THE PLAN'S POSSESSION THAT ARE RELEVANT TO THE PATIENT'S
CONDITION FOR WHICH THE PROPOSED
THERAPY HAS BEEN RECOMMENDED. THE MEDICAL RECORDS SHALL BE DISCLOSED SOLELY
TO THE EXPERT REVIEWERS AND SHALL BE USED SOLELY FOR THE PURPOSE OF THIS
SECTION.
(7) THE OPINIONS OF THE EXPERTS ON THE PANEL ARE RENDERED WITHIN THIRTY
DAYS AFTER THE REQUEST FOR REVIEW. IF THE ENROLLEE'S PHYSICIAN DETERMINES
THAT THE PROPOSED THERAPY WOULD BE SIGNIFICANTLY LESS EFFECTIVE IF NOT
PROMPTLY INITIATED, THE OPINIONS ARE RENDERED WITHIN SEVEN DAYS AFTER THE
REQUEST FOR REVIEW.
(8) EACH EXPERT ON THE PANEL PROVIDES THE CONTRACTING ENTITY WITH A
PROFESSIONAL OPINION AS TO WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE
THAT THE PROPOSED THERAPY IS LIKELY TO BE MORE BENEFICIAL TO THE ENROLLEE THAN
STANDARD THERAPIES.
(9) EACH EXPERT'S OPINION IS PRESENTED IN WRITTEN FORM AND INCLUDES THE
FOLLOWING INFORMATION:
(a) A DESCRIPTION OF THE PATIENT'S CONDITION;
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO DETERMINING
WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE PROPOSED THERAPY
IS MORE LIKELY THAN NOT TO BE MORE BENEFICIAL TO THE ENROLLEE THAN STANDARD
THERAPIES;
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS PUBLISHED
IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR THE PUBLISHED OPINIONS OF
MEDICAL EXPERTS OR SPECIALTY SOCIETIES;
(d) A DESCRIPTION OF THE ENROLLEE'S SUITABILITY TO RECEIVE THE
PROPOSED THERAPY ACCORDING TO A TREATMENT PROTOCOL IN A CLINICAL TRIAL, IF
APPLICABLE.
(10) THE CONTRACTING ENTITY PROVIDES THE PLAN WITH THE OPINIONS OF THE
EXPERTS. THE PLAN SHALL MAKE THE EXPERTS' OPINIONS AVAILABLE TO THE ENROLLEE
AND THE ENROLLEE'S PHYSICIAN, UPON REQUEST.
(11) THE DECISION OF THE MAJORITY OF THE EXPERTS ON THE PANEL, RENDERED
PURSUANT TO DIVISION (B)(8) OF THIS SECTION, IS BINDING ON THE PLAN.
IF THE OPINIONS OF THE EXPERTS ON THE PANEL ARE EVENLY DIVIDED AS TO WHETHER
THE THERAPY SHOULD BE COVERED, THEN THE PLAN'S FINAL DECISION SHALL BE IN
FAVOR OF
COVERAGE. IF LESS THAN A MAJORITY OF THE EXPERTS ON THE PANEL RECOMMEND
COVERAGE OF THE THERAPY, THE PLAN MAY, IN ITS DISCRETION, COVER THE THERAPY.
HOWEVER, ANY COVERAGE PROVIDED PURSUANT TO DIVISION (B)(11) OF THIS
SECTION IS SUBJECT TO THE TERMS AND CONDITIONS OF THE ENROLLEE'S CONTRACT WITH
THE PLAN.
(12) THE PLAN HAS WRITTEN POLICIES DESCRIBING THE EXTERNAL, INDEPENDENT
REVIEW PROCESS. THE PLAN SHALL DISCLOSE THE AVAILABILITY OF THE EXTERNAL,
INDEPENDENT REVIEW PROCESS IN THE PLAN'S EVIDENCE OF COVERAGE AND DISCLOSURE
FORMS.
Sec. 1753.40. THE SUPERINTENDENT OF INSURANCE AND THE DEPARTMENT OF HEALTH
SHALL CONTRACT OR AFFILIATE WITH ONE OR MORE PRIVATE, NONPROFIT ACCREDITING
ENTITIES FOR PURPOSES OF ACCREDITING THE INDEPENDENT REVIEW ENTITIES DESCRIBED
IN DIVISION (B)(2) OF SECTION 1753.39 of the Revised Code.
THE SUPERINTENDENT AND THE DIRECTOR OF HEALTH SHALL JOINTLY DEVELOP
ACCREDITATION STANDARDS FOR THE ACCREDITATION OF THE INDEPENDENT REVIEW
ENTITIES. THE ACCREDITATION STANDARDS SHALL INCLUDE MEASURES THAT ENSURE THE
INDEPENDENCE OF THE REVIEW ENTITY, THE CONFIDENTIALITY OF THE MEDICAL RECORDS,
AND THE QUALIFICATION AND INDEPENDENCE OF HEALTH CARE PROFESSIONALS PROVIDING
THE EXPERT OPINIONS REQUESTED OF THEM. THE SUPERINTENDENT AND THE DIRECTOR
SHALL DEVELOP THESE STANDARDS AND SECURE AN ARRANGEMENT WITH AN ACCREDITING
ENTITY OR ENTITIES BEFORE JANUARY 1, 1998.
Sec. 1753.43. (A) AS
USED IN THIS SECTION AND SECTION 1753.44 OF THE
REVISED CODE:
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT
LAYPERSON WITH AN AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO
RESULT IN ANY OF THE FOLLOWING:
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR,
WITH RESPECT TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER
UNBORN CHILD, IN SERIOUS JEOPARDY;
(b) SERIOUS IMPAIRMENT TO BODILY
FUNCTIONS;
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR
PART.
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING:
(a) A MEDICAL SCREENING EXAMINATION, AS
REQUIRED BY FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE
EMERGENCY DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES
ROUTINELY AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN
EMERGENCY MEDICAL CONDITION;
(b) SUCH FURTHER MEDICAL EXAMINATION
AND TREATMENT THAT ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN
EMERGENCY MEDICAL CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND BURN CENTER OF
THE HOSPITAL.
(3)(a) "STABILIZE" MEANS THE PROVISION OF SUCH
MEDICAL TREATMENT AS MAY BE NECESSARY TO ASSURE, WITHIN
REASONABLE MEDICAL PROBABILITY, THAT NO MATERIAL DETERIORATION
OF AN INDIVIDUAL'S MEDICAL CONDITION IS LIKELY TO RESULT FROM OR
OCCUR DURING A TRANSFER TO ANOTHER FACILITY, IF THE MEDICAL
CONDITION COULD RESULT IN ANY OF THE FOLLOWING:
(i) PLACING THE HEALTH OF THE INDIVIDUAL OR,
WITH RESPECT TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER
UNBORN CHILD, IN SERIOUS JEOPARDY;
(ii) SERIOUS IMPAIRMENT TO BODILY
FUNCTIONS;
(iii) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN
OR PART.
(b) IN THE CASE OF A WOMAN HAVING CONTRACTIONS,
"STABILIZE" MEANS SUCH MEDICAL TREATMENT AS MAY BE NECESSARY TO
DELIVER, INCLUDING THE PLACENTA.
(4) "STABILIZED" MEANS THAT NO MATERIAL DETERIORATION
OF AN INDIVIDUAL'S MEDICAL CONDITION, AS DESCRIBED IN DIVISION
(A)(3)(a) OF THIS SECTION, IS LIKELY, WITHIN REASONABLE
MEDICAL PROBABILITY, TO RESULT FROM OR OCCUR DURING THE TRANSFER OF THE
INDIVIDUAL FROM A FACILITY OR, IN THE CASE OF A WOMAN HAVING
CONTRACTIONS, THAT THE WOMAN HAS DELIVERED, INCLUDING THE
PLACENTA.
(B) A HEALTH CARE
PLAN SHALL PROVIDE COVERAGE FOR THE PROVISION OF EMERGENCY
SERVICES TO ENROLLEES WITH EMERGENCY MEDICAL CONDITIONS WITHOUT
REGARD TO THE DAY OR TIME THE SERVICES ARE RENDERED OR TO
WHETHER THE ENROLLEE, OR AN EMERGENCY PHYSICIAN TREATING THE
ENROLLEE, OBTAINED PRIOR AUTHORIZATION FOR THE SERVICES.
(C) A HEALTH CARE
PLAN SHALL COVER BOTH OF THE FOLLOWING:
(1) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A
PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT IF THE ENROLLEE PRESENTS
HIMSELF OR HERSELF WITH AN EMERGENCY MEDICAL CONDITION;
(2) EMERGENCY SERVICES PROVIDED TO AN ENROLLEE AT A
NONPARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT UP TO THE POINT OF
STABILIZATION IF THE ENROLLEE PRESENTS HIMSELF OR HERSELF WITH
AN EMERGENCY MEDICAL CONDITION AND ONE OF THE FOLLOWING
CIRCUMSTANCES APPLIES:
(a) DUE TO CIRCUMSTANCES BEYOND THE ENROLLEE'S
CONTROL, THE ENROLLEE WAS UNABLE TO UTILIZE A PARTICIPATING HOSPITAL'S
EMERGENCY DEPARTMENT WITHOUT SERIOUS THREAT TO LIFE OR
HEALTH.
(b) A PRUDENT LAYPERSON WITH AN AVERAGE
KNOWLEDGE OF HEALTH AND MEDICINE WOULD HAVE REASONABLY BELIEVED
THAT, UNDER THE CIRCUMSTANCES, THE TIME REQUIRED TO TRAVEL TO A
PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT COULD RESULT IN ONE OR MORE
OF THE ADVERSE HEALTH CONSEQUENCES DESCRIBED IN DIVISION
(A)(1) OF THIS SECTION.
(c) A PERSON AUTHORIZED BY THE HEALTH CARE PLAN
REFERS THE ENROLLEE TO AN EMERGENCY DEPARTMENT AND DOES NOT
SPECIFY A PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT.
(D) A HEALTH CARE
PLAN THAT PROVIDES COVERAGE FOR EMERGENCY MEDICAL SERVICES SHALL
INFORM ENROLLEES OF ALL OF THE FOLLOWING:
(1) THE SCOPE OF COVERAGE FOR EMERGENCY MEDICAL
SERVICES;
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES,
INCLUDING THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE
ACCESS SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY
SERVICES;
(3) ANY COST SHARING PROVISIONS FOR EMERGENCY
SERVICES;
(4) THE PROCEDURES FOR OBTAINING EMERGENCY AND OTHER
MEDICAL SERVICES, SO THAT ENROLLEES ARE FAMILIAR WITH THE
LOCATION OF THE EMERGENCY DEPARTMENTS OF PARTICIPATING HOSPITALS AND WITH THE
LOCATION AND AVAILABILITY OF OTHER PARTICIPATING FACILITIES OR
SETTINGS AT WHICH THEY COULD RECEIVE MEDICAL CARE.
Sec. 1753.44. (A) EXCEPT AS PROVIDED IN DIVISION
(B) OF THIS SECTION, A HEALTH
CARE PLAN IS NOT REQUIRED TO REIMBURSE AN EMERGENCY PHYSICIAN OR
THE EMERGENCY DEPARTMENT OF A HOSPITAL FOR ANY SERVICES OTHER THAN THOSE
MEDICALLY NECESSARY TO STABILIZE AN ENROLLEE, UNTIL THE
EMERGENCY DEPARTMENT HAS CONTACTED THE PLAN AND THERE IS
AGREEMENT BETWEEN THE PHYSICIAN AND THE PLAN CONCERNING
TREATMENT AND SERVICES TO BE PROVIDED BY THE PHYSICIAN AFTER THE
ENROLLEE IS STABILIZED.
(B) A HEALTH CARE
PLAN SHALL REIMBURSE AN EMERGENCY PHYSICIAN AND THE EMERGENCY
DEPARTMENT OF A HOSPITAL FOR ANY ITEMS OR SERVICES THAT ARE NOT NECESSARY TO
STABILIZE THE PATIENT BUT ARE DETERMINED BY THE PHYSICIAN TO BE
MEDICALLY NECESSARY, IF ANY OF THE FOLLOWING OCCURS:
(1) AFTER A DOCUMENTED GOOD FAITH EFFORT, THE
EMERGENCY DEPARTMENT IS UNABLE TO REACH THE PLAN WITHIN THIRTY
MINUTES AFTER THE INITIAL EXAMINATION OF THE ENROLLEE OR, IF THE
ENROLLEE NEEDS TO BE STABILIZED, WITHIN THIRTY MINUTES AFTER
STABILIZATION.
(2) THE EMERGENCY DEPARTMENT HAS CONTACTED THE PLAN AS
REQUIRED IN DIVISION (B)(1) OF
THIS SECTION, AND HAS NOT RECEIVED A DENIAL FROM THE PLAN WITHIN
THIRTY MINUTES AFTER THE INITIAL CONTACT, UNLESS THE PLAN CAN
DOCUMENT THAT IT MADE AN UNSUCCESSFUL GOOD FAITH EFFORT TO REACH
THE EMERGENCY DEPARTMENT WITHIN THIRTY MINUTES AFTER RECEIVING
THE REQUEST FOR AUTHORIZATION.
(3) THE EMERGENCY DEPARTMENT SUCCESSFULLY CONTACTED
THE PLAN AND RECEIVED A DENIAL FROM A PERSON OTHER THAN A
PARTICIPATING PHYSICIAN AND, WITHIN THIRTY MINUTES AFTER THAT
DENIAL IS COMMUNICATED TO THE EMERGENCY DEPARTMENT, EITHER OF
THE FOLLOWING OCCURS:
(a) A PARTICIPATING PHYSICIAN AUTHORIZED BY THE
PLAN TO REVIEW DENIALS REVERSES THE DENIAL.
(b) A PARTICIPATING PHYSICIAN AUTHORIZED BY THE
PLAN TO REVIEW DENIALS DOES NOT COMMUNICATE A DETERMINATION
AFFIRMING THE DENIAL, UNLESS THE TREATING PHYSICIAN WAIVES THE
REQUIREMENT FOR SUCH DETERMINATION.
(C) A HEALTH PLAN
SHALL IMMEDIATELY ARRANGE FOR AN ALTERNATIVE PLAN OF TREATMENT FOR
AN ENROLLEE IF A NONPARTICIPATING EMERGENCY PHYSICIAN AND THE
PLAN CANNOT REACH AN AGREEMENT ON SERVICES NECESSARY BEYOND
THOSE IMMEDIATELY NEEDED TO STABILIZE THE ENROLLEE. THE
ALTERNATIVE PLAN OF TREATMENT SHALL REQUIRE THAT A PARTICIPATING
PHYSICIAN WITH PRIVILEGES AT THE HOSPITAL ARRIVE PROMPTLY AT THE HOSPITAL'S
EMERGENCY DEPARTMENT AND ASSUME RESPONSIBILITY
FOR THE ENROLLEE'S TREATMENT OR, WITH THE AGREEMENT OF THE
TREATING PHYSICIAN OR ANY OTHER HEALTH PROFESSIONAL IN THE
EMERGENCY DEPARTMENT, THAT ONE OF THE FOLLOWING OCCURS:
(1) AN ARRANGEMENT IS MADE FOR TRANSFER OF THE ENROLLEE
TO ANOTHER FACILITY USING MEDICAL RESOURCES CONSISTENT WITH THE
ENROLLEE'S CONDITION;
(2) AN APPOINTMENT IS MADE WITH A PARTICIPATING
PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL FOR TREATMENT NEEDED
BY THE ENROLLEE;
(3) ANOTHER ARRANGEMENT IS MADE FOR TREATMENT OF THE
ENROLLEE.
(D) A HEALTH CARE
PLAN THAT ARRANGES FOR, OR OTHERWISE COVERS, URGENT CARE
SERVICES AND COMPREHENSIVE PRIMARY CARE, MAY IMPOSE DIFFERENT
COST-SHARING ON THE ENROLLEE FOR THE FOLLOWING:
(1) USE OF AN EMERGENCY DEPARTMENT AS OPPOSED TO
ANOTHER SETTING;
(2) USE OF A NONPARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT AS
OPPOSED TO A PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT UNLESS, DUE TO
CIRCUMSTANCES BEYOND THE ENROLLEE'S CONTROL, THE ENROLLEE WAS
UNABLE TO UTILIZE A PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT WITHOUT
SERIOUS THREAT TO LIFE OR HEALTH, OR A PRUDENT LAYPERSON WITH AN
AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE WOULD HAVE REASONABLY
BELIEVED THAT, UNDER THE CIRCUMSTANCES, THE TIME REQUIRED TO TRAVEL
TO A PARTICIPATING HOSPITAL'S EMERGENCY DEPARTMENT COULD RESULT IN ONE OR
MORE OF THE ADVERSE HEALTH CONSEQUENCES DESCRIBED IN DIVISION
(A)(1) OF SECTION 1753.43 OF
THE REVISED CODE.
Sec. 1753.46. EACH HEALTH CARE PLAN SHALL IMPLEMENT A COMPREHENSIVE
QUALITY ASSURANCE PROGRAM THAT DOES ALL OF THE FOLLOWING:
(A) IDENTIFIES A CORPORATE BOARD OR COMMITTEE OR DESIGNATES AN
EXECUTIVE STAFF PERSON RESPONSIBLE FOR PROGRAM IMPLEMENTATION AND COMPLIANCE;
(B) ASSURES THE QUALITY OF PROVIDERS AND FACILITIES WITHIN THE
PLAN THROUGH CREDENTIALING, RECREDENTIALING, AND MONITORING PROCEDURES;
(C) REQUIRES ONGOING MONITORING OF QUALITY ASSURANCE PROGRAMS,
INCLUDING ITS QUALITY ASSESSMENT PROGRAM AND QUALITY IMPROVEMENT PROGRAM AS
PROVIDED IN SECTION 1753.47 of the Revised Code.
(D) ASSURES A PROCESS FOR COMPLIANCE BY ANY ENTITY OR ENTITIES
WITH WHICH THE PLAN CONTRACTS FOR SERVICES;
(E) INCLUDES A PROCESS TO TAKE REMEDIAL ACTION TO CORRECT QUALITY
PROBLEMS.
Sec. 1753.47. TO IMPLEMENT ITS QUALITY ASSURANCE PROGRAM,
A HEALTH CARE PLAN SHALL DO BOTH OF THE FOLLOWING:
(A) DEVELOP AND MAINTAIN
THE INFRASTRUCTURE AND DISCLOSURE SYSTEMS NECESSARY TO MEASURE
AND REPORT, ON A REGULAR BASIS, THE QUALITY OF HEALTH CARE
SERVICES PROVIDED TO COVERED PERSONS, APPROPRIATE TO THE TYPE OF
PLAN, BASED ON SYSTEMATIC COLLECTION, ANALYSIS, AND REPORTING OF
RELEVANT DATA. THE PLAN SHALL ASSURE THAT PARTICIPATING
PHYSICIANS HAVE THE OPPORTUNITY TO PARTICIPATE IN DEVELOPING,
IMPLEMENTING, AND EVALUATING THE QUALITY IMPROVEMENT SYSTEM AND
ALL OTHER PROGRAMS IMPLEMENTED BY THE PLAN RELATED TO THE
UTILIZATION OF HEALTH CARE SERVICES. PARTICIPATING PHYSICIANS
MUST BE INCLUDED IN THE DATA ASSESSMENTS, STATISTICAL ANALYSES,
AND OUTCOME INTERPRETATIONS BEING DERIVED FROM PROGRAMS
MONITORING THE UTILIZATION OF HEALTH CARE SERVICES.
(B) DEVELOP AND MAINTAIN
AN ORGANIZATIONAL PROGRAM FOR DESIGNING, MEASURING, ASSESSING,
AND IMPROVING THE PROCESSES AND OUTCOMES OF HEALTH CARE. EACH
PLAN SHALL FILE A WRITTEN DESCRIPTION OF ITS QUALITY ASSESSMENT
PROGRAM AND QUALITY IMPROVEMENT PROGRAM WITH THE DEPARTMENT OF
INSURANCE, AND INCLUDE A SIGNED CERTIFICATION THAT THE FILING
MEETS THE REQUIREMENTS OF THIS SECTION.
(1) THE PROGRAMS SHALL PROVIDE COVERED PERSONS WITH THE
OPPORTUNITY TO COMMENT ON THE QUALITY IMPROVEMENT PROCESS;
ESTABLISH AN INTERNAL SYSTEM CAPABLE OF IDENTIFYING
OPPORTUNITIES TO IMPROVE CARE, WHICH SYSTEM IS STRUCTURED TO
IDENTIFY PRACTICES THAT RESULT IN IMPROVED HEALTH CARE OUTCOMES,
TO IDENTIFY PROBLEMATIC UTILIZATION PATTERNS, AND TO IDENTIFY THOSE
PROVIDERS THAT MAY BE RESPONSIBLE FOR EITHER EXEMPLARY OR
PROBLEMATIC PATTERNS; AND USE THE FINDINGS GENERATED BY THE
SYSTEM TO WORK, ON A CONTINUING BASIS, WITH PARTICIPATING
PROVIDERS AND OTHER STAFF TO IMPROVE THE HEALTH CARE DELIVERED
TO COVERED PERSONS.
(2) A HEATH CARE PLAN'S QUALITY IMPROVEMENT PROGRAM SHALL
INCLUDE A WRITTEN STATEMENT OF OBJECTIVES, LINES OF AUTHORITY
AND ACCOUNTABILITY, EVALUATION TOOLS, AND PERFORMANCE
IMPROVEMENT ACTIVITIES; REQUIRE AN ANNUAL EFFECTIVENESS REVIEW
OF THE PROGRAM; AND PROVIDE A WRITTEN QUALITY IMPROVEMENT PLAN
THAT DESCRIBES HOW THE HEALTH CARE PLAN INTENDS TO DO ALL OF THE
FOLLOWING:
(a) ANALYZE BOTH PROCESSES AND OUTCOMES OF CARE, INCLUDING FOCUSED
REVIEW OF INDIVIDUAL CASES AS APPROPRIATE, TO DISCERN THE CAUSES OF VARIATION;
(b) IDENTIFY THE TARGETED DIAGNOSES AND TREATMENTS TO BE REVIEWED
BY THE QUALITY IMPROVEMENT PROGRAM EACH YEAR, BASED ON CONSIDERATION OF
PRACTICES AND DIAGNOSES THAT AFFECT A SUBSTANTIAL NUMBER OF THE HEALTH CARE
PLAN'S COVERED PERSONS, OR THAT COULD PLACE COVERED PERSONS AT SERIOUS RISK;
(c) USE A RANGE OF APPROPRIATE METHODS TO ANALYZE QUALITY,
INCLUDING COLLECTION AND ANALYSIS OF INFORMATION ON OVER-UTILIZATION AND
UNDER-UTILIZATION OF SERVICES; EVALUATION OF COURSES OF TREATMENT AND OUTCOMES
BASED ON CURRENT MEDICAL RESEARCH, KNOWLEDGE, STANDARDS, AND PRACTICE
GUIDELINES; AND COLLECTION AND ANALYSIS OF INFORMATION SPECIFIC TO COVERED
PERSONS OR PROVIDERS;
(d) COMPARE PROGRAM FINDINGS WITH PAST PERFORMANCE, INTERNAL
GOALS, AND EXTERNAL STANDARDS;
(e) MEASURE THE PERFORMANCE OF PARTICIPATING PROVIDERS AND
CONDUCT PEER REVIEW ACTIVITIES;
(f) UTILIZE TREATMENT PROTOCOLS AND PRACTICE PARAMETERS DEVELOPED
WITH APPROPRIATE CLINICAL INPUT;
(g) IMPLEMENT IMPROVEMENT STRATEGIES RELATED TO PROGRAM FINDINGS;
(h) EVALUATE PERIODICALLY, BUT NOT LESS THAN ANNUALLY, THE
EFFECTIVENESS OF THE IMPROVEMENT STRATEGIES.
Sec. 1753.48. (A) THE
QUALITY ASSURANCE PROGRAM OF EACH HEALTH CARE PLAN
SHALL BE SUBJECT TO PERIODIC EXTERNAL VERIFICATION, AS
FOLLOWS:
(1) A PANEL OF QUALIFIED HEALTH PROFESSIONALS EXPERIENCED
IN EVALUATING THE DELIVERY OF HEALTH CARE AND FAMILIAR WITH THE OPERATION AND
PARAMETERS OF THE TYPE OF PLAN UNDER REVIEW SHALL PERIODICALLY CONDUCT AN
ONSITE MEDICAL SURVEY OF THE HEALTH DELIVERY SYSTEM
OF THE PLAN. THE SURVEY SHALL INCLUDE A REVIEW OF THE
PROCEDURES FOR REGULATING UTILIZATION, PEER REVIEW MECHANISMS,
INTERNAL PROCEDURES OF ASSURING QUALITY OF CARE, AND THE OVERALL
PERFORMANCE OF THE PLAN IN PROVIDING HEALTH CARE BENEFITS AND
MEETING THE HEALTH CARE NEEDS OF THE ENROLLEES.
(2) SURVEYS PERFORMED PURSUANT TO DIVISION
(A)(1) OF THIS SECTION SHALL BE
CONDUCTED AT THE REQUEST OF THE SUPERINTENDENT OF INSURANCE AS
OFTEN AS THE SUPERINTENDENT CONSIDERS NECESSARY TO ASSURE THE
PROTECTION OF SUBSCRIBERS AND ENROLLEES, BUT NOT LESS FREQUENTLY
THAN ONCE EVERY THREE YEARS. NOTHING IN THIS SECTION SHALL BE
CONSTRUED TO REQUIRE THE PANEL CONDUCTING THE SURVEY TO VISIT
EVERY CLINIC, HOSPITAL OFFICE, OR OTHER FACILITY OF THE HEALTH
CARE PLAN.
(3) REVIEWS CONDUCTED BY PROFESSIONAL STANDARDS REVIEW
ORGANIZATIONS AND SURVEYS AND AUDITS CONDUCTED BY OTHER
GOVERNMENTAL ENTITIES SHALL BE DEEMED
TO MEET THE REQUIREMENTS OF DIVISION
(A) OF THIS SECTION.
(B) THIS SECTION DOES
NOT REQUIRE ACCREDITATION OF HEALTH CARE PLANS BY INDEPENDENT,
PRIVATE ORGANIZATIONS. TO THE EXTENT THAT ACCREDITATION OF A
HEALTH CARE PLAN BY A PRIVATE ORGANIZATION MEETS FEDERAL QUALITY
REVIEW REQUIREMENTS, THE CORRESPONDING REQUIREMENTS OF DIVISION
(A) OF THIS SECTION ARE DEEMED
TO HAVE BEEN MET.
Sec. 1753.49. A HEALTH CARE PLAN THAT IS ACCREDITED BY THE NATIONAL
COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION ON ACCREDITATION OF
HEALTHCARE ORGANIZATIONS, THE UTILIZATION REVIEW ACCREDITATION COMMISSION, OR
ANY OTHER QUALIFIED ORGANIZATION DESIGNATED IN RULES ADOPTED BY THE
SUPERINTENDENT OF INSURANCE IN ACCORDANCE WITH CHAPTER 119. of the Revised Code, IS
DEEMED TO BE IN COMPLIANCE WITH THE REQUIREMENTS OF SECTIONS 1753.46 TO
1753.48 of the Revised Code.
Sec. 1753.51. (A) EACH HEALTH CARE PLAN SHALL ESTABLISH
A POLICY REGARDING THE AVAILABILITY AND CONFIDENTIALITY OF THOSE HEALTH
RECORDS MAINTAINED BY PROVIDERS AND HEALTH CARE FACILITIES TO MONITOR AND
EVALUATE THE QUALITY OF CARE, TO CONDUCT EVALUATIONS AND AUDITS, AND TO
DETERMINE ON A CONCURRENT OR RETROSPECTIVE BASIS THE NECESSITY OF AND
APPROPRIATENESS OF HEALTH CARE SERVICES PROVIDED TO ENROLLEES. THE POLICY
SHALL REQUIRE THE PROVIDER OR HEALTH CARE FACILITY TO MAKE THESE HEALTH
RECORDS AVAILABLE TO APPROPRIATE STATE AND FEDERAL AUTHORITIES INVOLVED IN
ASSESSING THE QUALITY OF CARE OR IN INVESTIGATING THE GRIEVANCES OR COMPLAINTS
OF ENROLLEES.
(B) IF AN ENROLLEE SIGNS A MEDICAL INFORMATION RELEASE FOR A
HEALTH CARE PLAN, THE RELEASE SHALL CLEARLY EXPLAIN WHAT INFORMATION MAY BE
DISCLOSED UNDER THE TERMS OF THE RELEASE. IF A HEALTH CARE PLAN UTILIZES THIS
RELEASE TO REQUEST MEDICAL INFORMATION FROM A HEALTH CARE PROVIDER, THE PLAN
SHALL PROVIDE A COPY OF THE ENROLLEE'S RELEASE TO THE HEALTH CARE PROVIDER,
UPON REQUEST.
(C) EACH HEALTH CARE PLAN, PROVIDER, AND FACILITY SHALL COMPLY
WITH ALL APPLICABLE STATE AND FEDERAL LAWS RELATED TO THE CONFIDENTIALITY OF
MEDICAL OR HEALTH RECORDS.
Sec. 1753.66. AS USED IN SECTIONS 1753.66 TO 1753.75 of the Revised Code, UNLESS
OTHERWISE SPECIFICALLY PROVIDED:
(A) "ADVERSE DETERMINATION" MEANS A DETERMINATION BY A HEALTH
CARRIER OR ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION THAT AN ADMISSION,
AVAILABILITY OF CARE, CONTINUED STAY, OR OTHER HEALTH CARE SERVICE HAS BEEN
REVIEWED AND, BASED UPON THE INFORMATION PROVIDED, DOES NOT MEET THE HEALTH
CARRIER'S REQUIREMENTS FOR MEDICAL NECESSITY, APPROPRIATENESS, HEALTH CARE
SETTING, LEVEL OF CARE, OR EFFECTIVENESS, AND THAT THE REQUESTED SERVICE IS
THEREFORE DENIED, REDUCED, OR TERMINATED.
(B) "AMBULATORY REVIEW" MEANS UTILIZATION REVIEW OF HEALTH CARE
SERVICES PERFORMED OR PROVIDED IN AN OUTPATIENT SETTING.
(C) "APPEALS PROCEDURE" MEANS A FORMAL PROCESS IN WHICH A COVERED
PERSON, A REPRESENTATIVE OF A COVERED PERSON, AN ATTENDING PHYSICIAN, A
FACILITY, OR A HEALTH CARE PROVIDER CAN CONTEST AN ADVERSE DETERMINATION
RENDERED BY THE HEALTH CARRIER OR ITS DESIGNEE UTILIZATION REVIEW
ORGANIZATION.
(D) "CASE MANAGEMENT" MEANS A COORDINATED SET OF ACTIVITIES
CONDUCTED FOR INDIVIDUAL PATIENT MANAGEMENT OF SERIOUS, COMPLICATED,
PROTRACTED, OR OTHER SPECIFIED HEALTH CONDITIONS.
(E) "CERTIFICATION" MEANS A DETERMINATION BY A HEALTH CARRIER OR
ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION THAT AN ADMISSION, AVAILABILITY
OF CARE, CONTINUED STAY, OR OTHER HEALTH CARE SERVICE HAS BEEN REVIEWED AND,
BASED ON THE INFORMATION PROVIDED, SATISFIES THE HEALTH CARRIER'S REQUIREMENTS
FOR MEDICAL NECESSITY, APPROPRIATENESS, HEALTH CARE SETTING, LEVEL OF CARE,
AND EFFECTIVENESS.
(F) "CLINICAL PEER" MEANS A PHYSICIAN IN THE SAME OR SIMILAR
SPECIALTY AS TYPICALLY MANAGES THE MEDICAL CONDITION, PROCEDURE, OR TREATMENT
UNDER REVIEW.
(G) "CLINICAL REVIEW CRITERIA" MEANS THE WRITTEN SCREENING
PROCEDURES, DECISION ABSTRACTS, CLINICAL PROTOCOLS, AND PRACTICE GUIDELINES
USED BY THE HEALTH CARRIER TO DETERMINE THE NECESSITY AND APPROPRIATENESS OF
HEALTH CARE SERVICES.
(H) "CONCURRENT REVIEW" MEANS UTILIZATION REVIEW CONDUCTED DURING
A PATIENT'S HOSPITAL STAY OR COURSE OF TREATMENT.
(I) "COVERED PERSON" MEANS THE POLICYHOLDER, SUBSCRIBER,
ENROLLEE, OR OTHER INDIVIDUAL PARTICIPATING IN A HEALTH BENEFIT PLAN.
(J) "DISCHARGE PLANNING" MEANS THE FORMAL PROCESS FOR
DETERMINING, PRIOR TO DISCHARGE FROM A FACILITY, THE COORDINATION AND
MANAGEMENT OF THE CARE THAT A PATIENT RECEIVES FOLLOWING DISCHARGE FROM A
FACILITY.
(K) "FACILITY" MEANS AN INSTITUTION PROVIDING HEALTH CARE
SERVICES OR A HEALTH CARE SETTING, INCLUDING BUT NOT LIMITED TO HOSPITALS AND
OTHER LICENSED INPATIENT CENTERS, AMBULATORY SURGICAL OR TREATMENT CENTERS,
SKILLED NURSING CENTERS, RESIDENTIAL TREATMENT CENTERS, DIAGNOSTIC, LABORATORY
AND IMAGING CENTERS, AND REHABILITATION
AND OTHER THERAPEUTIC HEALTH SETTINGS.
(L) "HEALTH BENEFIT PLAN" MEANS A POLICY, CONTRACT, CERTIFICATE,
OR AGREEMENT ENTERED INTO, OFFERED, OR ISSUED BY A HEALTH CARRIER TO PROVIDE,
DELIVER, ARRANGE FOR, PAY FOR, OR REIMBURSE ANY OF THE COSTS OF HEALTH CARE
SERVICES.
(M) "HEALTH CARE PROFESSIONAL" MEANS A PHYSICIAN OR OTHER HEALTH
CARE PRACTITIONER WHO HAS A CURRENT NONRESTRICTED LICENSE, IS ACCREDITED, OR
IS CERTIFIED TO PERFORM SPECIFIED HEALTH SERVICES IN ACCORDANCE WITH THE LAW
OF THE STATE IN WHICH THE PROFESSIONAL PRACTICES.
(N) "HEALTH CARE PROVIDER" OR "PROVIDER" MEANS A HEALTH CARE
PROFESSIONAL OR A FACILITY.
(O) "HEALTH CARE SERVICES" MEANS SERVICES FOR THE DIAGNOSIS,
PREVENTION, TREATMENT, CURE, OR RELIEF OF A HEALTH CONDITION, ILLNESS, INJURY,
OR DISEASE.
(P) "HEALTH CARRIER" MEANS AN ENTITY SUBJECT TO REGULATION UNDER
TITLE XVII OR XXXIX of the Revised Code THAT CONTRACTS OR OFFERS
TO CONTRACT TO PROVIDE, DELIVER, ARRANGE FOR, PAY FOR, OR REIMBURSE ANY OF THE
COSTS OF HEALTH CARE SERVICES, INCLUDING A SICKNESS AND ACCIDENT INSURANCE
COMPANY, A HEALTH MAINTENANCE ORGANIZATION, OR ANY OTHER ENTITY PROVIDING A
PLAN OF HEALTH INSURANCE, HEALTH BENEFITS, OR HEALTH SERVICES.
(Q) "PARTICIPATING PROVIDER" MEANS A PROVIDER THAT, UNDER A
CONTRACT WITH THE HEALTH CARRIER OR WITH ITS CONTRACTOR OR SUBCONTRACTOR, HAS
AGREED TO PROVIDE HEALTH CARE SERVICES TO COVERED PERSONS WITH AN EXPECTATION
OF RECEIVING PAYMENT, OTHER THAN COINSURANCE, COPAYMENTS, OR DEDUCTIBLES,
DIRECTLY OR INDIRECTLY FROM THE HEALTH CARRIER.
(R) "PERSON" MEANS AN INDIVIDUAL, A CORPORATION, A PARTNERSHIP,
AN ASSOCIATION, A JOINT VENTURE, A JOINT STOCK COMPANY, A TRUST, AN
UNINCORPORATED ORGANIZATION, OR OTHER SIMILAR ENTITY, OR ANY COMBINATION
THEREOF.
(S) "PROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW THAT IS
CONDUCTED PRIOR TO AN ADMISSION OR A COURSE OF TREATMENT.
(T) "RETROSPECTIVE REVIEW" MEANS UTILIZATION REVIEW OF MEDICAL
NECESSITY THAT IS CONDUCTED AFTER SERVICES HAVE BEEN PROVIDED TO A PATIENT.
"RETROSPECTIVE REVIEW" DOES NOT INCLUDE THE REVIEW OF A CLAIM THAT IS LIMITED
TO AN EVALUATION OF REIMBURSEMENT LEVELS, VERACITY OF DOCUMENTATION, ACCURACY
OF CODING, OR ADJUDICATION OF PAYMENT.
(U) "SECOND OPINION" MEANS AN OPPORTUNITY OR REQUIREMENT TO
OBTAIN A CLINICAL EVALUATION BY A PROVIDER OTHER THAN THE ONE ORIGINALLY
MAKING A RECOMMENDATION FOR PROPOSED HEALTH CARE SERVICES TO ASSESS THE
CLINICAL NECESSITY AND APPROPRIATENESS OF THE INITIAL PROPOSED HEALTH CARE
SERVICES.
(V) "UTILIZATION REVIEW" MEANS A PROCESS USED TO MONITOR THE USE
OF, OR EVALUATE THE CLINICAL NECESSITY, APPROPRIATENESS, EFFICACY, OR
EFFICIENCY OF, HEALTH CARE SERVICES, PROCEDURES, OR SETTINGS. AREAS OF REVIEW
MAY INCLUDE AMBULATORY REVIEW, PROSPECTIVE REVIEW, SECOND OPINION,
CERTIFICATION, CONCURRENT REVIEW, CASE MANAGEMENT, DISCHARGE PLANNING, OR
RETROSPECTIVE REVIEW.
(W) "UTILIZATION REVIEW ORGANIZATION" MEANS AN ENTITY THAT
CONDUCTS UTILIZATION REVIEW, OTHER THAN A HEALTH CARE PROVIDER PERFORMING A
REVIEW FOR ITS OWN HEALTH BENEFIT PLANS.
Sec. 1753.67. (A)
SECTIONS 1753.66 TO 1753.75 OF THE
REVISED
CODE APPLY TO ANY HEALTH
CARRIER THAT PROVIDES OR PERFORMS UTILIZATION REVIEW SERVICES
AND TO ANY DESIGNEE OF THE HEALTH CARRIER, OR TO ANY UTILIZATION
REVIEW ORGANIZATION THAT PERFORMS UTILIZATION REVIEW FUNCTIONS
ON BEHALF OF THE HEALTH CARRIER.
(B)(1) EACH HEALTH
CARRIER SHALL BE RESPONSIBLE FOR MONITORING ALL UTILIZATION
REVIEW ACTIVITIES CARRIED OUT BY, OR ON BEHALF OF, THE HEALTH
CARRIER AND FOR ENSURING THAT ALL REQUIREMENTS OF SECTIONS
1753.66 TO 1753.75 OF THE
REVISED
CODE, AND ANY RULES ADOPTED
THEREUNDER, ARE MET. THE HEALTH CARRIER SHALL ALSO ENSURE THAT
APPROPRIATE PERSONNEL HAVE OPERATIONAL RESPONSIBILITY FOR THE
CONDUCT OF THE HEALTH CARRIER'S UTILIZATION REVIEW
PROGRAM.
(2) IF A HEALTH CARRIER CONTRACTS TO HAVE A UTILIZATION
REVIEW ORGANIZATION OR OTHER ENTITY PERFORM THE UTILIZATION
REVIEW FUNCTIONS REQUIRED BY SECTIONS 1753.66 TO 1753.75 OF THE
REVISED
CODE OR ANY RULES ADOPTED
THEREUNDER, THE SUPERINTENDENT OF INSURANCE SHALL HOLD THE
HEALTH CARRIER RESPONSIBLE FOR MONITORING THE ACTIVITIES OF THE
UTILIZATION REVIEW ORGANIZATION OR OTHER ENTITY AND FOR ENSURING
THAT THE REQUIREMENTS OF THOSE SECTIONS AND RULES ARE
MET.
Sec. 1753.68. A HEALTH CARRIER THAT CONDUCTS UTILIZATION
REVIEW SHALL PREPARE A WRITTEN UTILIZATION REVIEW PROGRAM THAT DESCRIBES ALL
REVIEW ACTIVITIES, BOTH DELEGATED AND NONDELEGATED, FOR COVERED SERVICES
PROVIDED, INCLUDING THE FOLLOWING:
(A) PROCEDURES TO EVALUATE THE CLINICAL NECESSITY,
APPROPRIATENESS,
EFFICACY, OR EFFICIENCY OF HEALTH SERVICES;
(B) DATA SOURCES AND CLINICAL REVIEW CRITERIA USED IN MAKING
DECISIONS;
(C) THE PROCESS FOR CONDUCTING APPEALS OF ADVERSE DETERMINATIONS;
(D) MECHANISMS TO ENSURE CONSISTENT APPLICATION OF CRITERIA AND
COMPATIBLE DECISIONS;
(E) DATA COLLECTION PROCESSES AND ANALYTICAL METHODS USED IN
ASSESSING
UTILIZATION OF HEALTH CARE SERVICES;
(F) PROVISIONS FOR ASSURING CONFIDENTIALITY OF CLINICAL AND
PROPRIETARY INFORMATION;
(G) THE ORGANIZATIONAL STRUCTURE, SUCH AS UTILIZATION REVIEW,
QUALITY ASSURANCE, OR OTHER COMMITTEE, THAT PERIODICALLY ASSESSES UTILIZATION
REVIEW ACTIVITIES AND REPORTS TO THE HEALTH CARRIER'S GOVERNING BODY;
(H) THE STAFF POSITION FUNCTIONALLY RESPONSIBLE FOR DAY-TO-DAY
PROGRAM MANAGEMENT;
(I) DEFINED METHODS BY WHICH GUIDELINES ARE APPROVED AND
COMMUNICATED TO PROVIDERS.
Sec. 1753.69. THE UTILIZATION REVIEW PROGRAM OF A HEALTH
CARRIER SHALL BE IMPLEMENTED IN ACCORDANCE WITH ALL OF THE
FOLLOWING:
(A) THE PROGRAM SHALL
USE DOCUMENTED CLINICAL REVIEW CRITERIA THAT ARE BASED ON SOUND
CLINICAL EVIDENCE AND ARE EVALUATED PERIODICALLY TO ASSURE
ONGOING EFFICACY. A HEALTH CARRIER MAY DEVELOP ITS OWN CLINICAL
REVIEW CRITERIA OR MAY PURCHASE OR LICENSE SUCH CRITERIA FROM
QUALIFIED VENDORS. A HEALTH BENEFIT PLAN SHALL MAKE ITS CLINICAL
REVIEW RATIONALE AVAILABLE UPON REQUEST TO AUTHORIZED GOVERNMENT
AGENCIES.
(B) QUALIFIED HEALTH
CARE PROFESSIONALS SHALL ADMINISTER THE PROGRAM AND OVERSEE
REVIEW DECISIONS. A CLINICAL PEER SHALL EVALUATE THE CLINICAL
APPROPRIATENESS OF ADVERSE DETERMINATIONS THAT ARE THE SUBJECT OF AN
APPEAL.
(C) THE HEALTH CARRIER
SHALL ISSUE UTILIZATION REVIEW DECISIONS IN A TIMELY MANNER
PURSUANT TO THE REQUIREMENTS OF SECTIONS 1753.70 AND 1753.71 OF
THE REVISED
CODE AND THE ENROLLEE GRIEVANCE
REQUIREMENTS. THE CARRIER SHALL OBTAIN INFORMATION REQUIRED TO
MAKE A UTILIZATION REVIEW DECISION, INCLUDING PERTINENT CLINICAL
INFORMATION, AND SHALL ESTABLISH A PROCESS TO ENSURE THAT
UTILIZATION REVIEWERS APPLY CLINICAL REVIEW CRITERIA
CONSISTENTLY.
(D) IF THE HEALTH
CARRIER DELEGATES ANY UTILIZATION REVIEW ACTIVITIES TO A
UTILIZATION REVIEW ORGANIZATION, THE CARRIER SHALL MAINTAIN
ADEQUATE OVERSIGHT, WHICH SHALL INCLUDE ALL OF THE
FOLLOWING:
(1) A WRITTEN DESCRIPTION OF THE ORGANIZATION'S
ACTIVITIES AND RESPONSIBILITIES, INCLUDING REPORTING
REQUIREMENTS;
(2) EVIDENCE OF FORMAL APPROVAL OF THE ORGANIZATION'S
PROGRAM BY THE HEALTH CARRIER;
(3) A PROCESS BY WHICH THE HEALTH CARRIER EVALUATES THE
PERFORMANCE OF THE ORGANIZATION.
(E) THE HEALTH CARRIER
OR ITS DESIGNEE UTILIZATION REVIEW ORGANIZATION SHALL PROVIDE
COVERED PERSONS AND PARTICIPATING PROVIDERS WITH ACCESS TO ITS
REVIEW STAFF BY MEANS OF A TOLL-FREE TELEPHONE
NUMBER OR COLLECT-CALL TELEPHONE LINE.
(F) WHEN CONDUCTING
PROSPECTIVE OR CONCURRENT REVIEW, THE HEALTH CARRIER OR ITS
DESIGNEE UTILIZATION REVIEW ORGANIZATION SHALL COLLECT ONLY THE
INFORMATION NECESSARY TO CERTIFY THE ADMISSION, PROCEDURE OR
TREATMENT, LENGTH OF STAY, FREQUENCY, AND DURATION OF
SERVICES.
(G) COMPENSATION TO
PERSONS PROVIDING UTILIZATION REVIEW SERVICES FOR THE HEALTH
CARRIER SHALL NOT CONTAIN INCENTIVES, DIRECT OR INDIRECT, FOR
THEM TO MAKE INAPPROPRIATE REVIEW DECISIONS.
Sec. 1753.70. (A) AS USED IN THIS SECTION:
(1) "COVERED PERSON" INCLUDES THE REPRESENTATIVE OF A COVERED PERSON.
(2) "NECESSARY INFORMATION" INCLUDES THE RESULTS OF ANY FACE-TO-FACE
CLINICAL
EVALUATION OR SECOND OPINION THAT MAY BE REQUIRED.
(B) A HEALTH CARRIER SHALL MAINTAIN WRITTEN PROCEDURES FOR MAKING
UTILIZATION REVIEW DECISIONS AND FOR NOTIFYING COVERED PERSONS, AND PROVIDERS
ACTING ON BEHALF OF COVERED PERSONS, OF ITS DECISIONS.
(C) FOR INITIAL DETERMINATIONS, A HEALTH CARRIER SHALL MAKE THE
DETERMINATION WITHIN TWO BUSINESS DAYS OF OBTAINING ALL NECESSARY INFORMATION
REGARDING A PROPOSED ADMISSION, PROCEDURE, OR SERVICE REQUIRING A REVIEW
DETERMINATION.
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN ADMISSION, PROCEDURE, OR
SERVICE, THE CARRIER SHALL NOTIFY THE PROVIDER RENDERING THE SERVICE BY
TELEPHONE WITHIN SEVENTY-TWO HOURS OF MAKING THE INITIAL CERTIFICATION, AND
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION OF THE TELEPHONE NOTIFICATION
TO THE COVERED PERSON AND THE PROVIDER WITHIN TWO BUSINESS DAYS OF MAKING THE
INITIAL CERTIFICATION.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE CARRIER SHALL NOTIFY THE
PROVIDER RENDERING THE SERVICE BY TELEPHONE WITHIN SEVENTY-TWO HOURS OF MAKING
THE ADVERSE DETERMINATION, AND SHALL PROVIDE WRITTEN OR ELECTRONIC
CONFIRMATION OF THE TELEPHONE NOTIFICATION TO THE COVERED PERSON AND THE
PROVIDER WITHIN ONE BUSINESS DAY OF MAKING THE ADVERSE DETERMINATION.
(D) FOR CONCURRENT REVIEW DETERMINATIONS, A HEALTH CARRIER SHALL
MAKE THE DETERMINATION WITHIN ONE BUSINESS DAY OF OBTAINING ALL NECESSARY
INFORMATION.
(1) IN THE CASE OF A DETERMINATION TO CERTIFY AN EXTENDED STAY OR
ADDITIONAL SERVICES, THE CARRIER SHALL NOTIFY BY TELEPHONE THE PROVIDER
RENDERING THE SERVICE WITHIN ONE BUSINESS DAY OF MAKING THE CERTIFICATION, AND
SHALL PROVIDE WRITTEN OR ELECTRONIC CONFIRMATION TO THE COVERED PERSON AND THE
PROVIDER WITHIN ONE BUSINESS DAY AFTER THE TELEPHONE
NOTIFICATION. THE WRITTEN NOTIFICATION SHALL INCLUDE THE NUMBER OF EXTENDED
DAYS OR NEXT REVIEW DATE, THE NEW TOTAL NUMBER OF DAYS OR SERVICES APPROVED,
AND THE DATE OF ADMISSION OR INITIATION OF SERVICES.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE CARRIER SHALL NOTIFY BY
TELEPHONE THE PROVIDER RENDERING THE SERVICE WITHIN TWENTY-FOUR HOURS OF
MAKING THE ADVERSE DETERMINATION, AND SHALL PROVIDE WRITTEN OR ELECTRONIC
CONFIRMATION TO THE COVERED PERSON AND THE PROVIDER WITHIN ONE BUSINESS DAY OF
THE TELEPHONE NOTIFICATION. THE SERVICE SHALL BE CONTINUED WITHOUT LIABILITY
TO THE COVERED PERSON UNTIL THE COVERED PERSON HAS BEEN NOTIFIED OF THE
DETERMINATION.
(E) FOR RETROSPECTIVE REVIEW DETERMINATIONS, A HEALTH CARRIER
SHALL MAKE
THE DETERMINATION WITHIN THIRTY BUSINESS DAYS OF RECEIVING ALL NECESSARY
INFORMATION.
(1) IN THE CASE OF A CERTIFICATION, THE CARRIER MAY NOTIFY IN WRITING THE
COVERED PERSON AND THE PROVIDER RENDERING THE SERVICE.
(2) IN THE CASE OF AN ADVERSE DETERMINATION, THE CARRIER SHALL NOTIFY IN
WRITING THE PROVIDER RENDERING THE SERVICE AND THE COVERED PERSON WITHIN FIVE
BUSINESS DAYS OF MAKING THE ADVERSE DETERMINATION.
(F) THE TIME FRAMES SET FORTH IN DIVISIONS (C),
(D), AND (E) OF THIS SECTION FOR INITIAL DETERMINATIONS AND
NOTIFICATIONS SHALL PREVAIL UNLESS THE SERIOUSNESS OF THE MEDICAL CONDITION OF
THE COVERED PERSON OTHERWISE REQUIRES A MORE TIMELY RESPONSE FROM THE HEALTH
BENEFIT PLAN. THE HEALTH BENEFIT PLAN SHALL MAINTAIN WRITTEN PROCEDURES FOR
MAKING EXPEDITED UTILIZATION REVIEW DECISIONS AND FOR NOTIFYING COVERED
PERSONS OR PROVIDERS WHEN WARRANTED BY THE MEDICAL CONDITION OF THE COVERED
PERSON.
(G) A WRITTEN NOTIFICATION OF AN ADVERSE DETERMINATION SHALL
INCLUDE THE PRINCIPAL REASON OR REASONS FOR THE DETERMINATION, THE INSTRUCTION
FOR INITIATING AN APPEAL OR RECONSIDERATION OF THE DETERMINATION, AND THE
INSTRUCTIONS FOR REQUESTING A WRITTEN STATEMENT OF THE CLINICAL RATIONALE
USED TO MAKE THE DETERMINATION. A HEALTH CARRIER SHALL PROVIDE THE CLINICAL
RATIONALE IN WRITING FOR AN ADVERSE DETERMINATION
TO ANY PARTY WHO RECEIVED
NOTICE OF THE ADVERSE DETERMINATION AND WHO FOLLOWS THE PROCEDURES FOR A
REQUEST.
(H) A HEALTH CARRIER SHALL HAVE WRITTEN PROCEDURES TO ADDRESS THE
FAILURE OR INABILITY OF A PROVIDER OR A COVERED PERSON TO PROVIDE ALL
NECESSARY INFORMATION FOR REVIEW. IF THE PROVIDER OR COVERED PERSON WILL NOT
RELEASE NECESSARY INFORMATION, THE HEALTH CARRIER MAY DENY CERTIFICATION.
Sec. 1753.71. (A) IN A
CASE INVOLVING AN INITIAL DETERMINATION OR A CONCURRENT REVIEW
DETERMINATION, A HEALTH CARRIER SHALL GIVE THE PROVIDER
RENDERING THE SERVICE AN OPPORTUNITY TO REQUEST IN WRITING ON
BEHALF OF THE COVERED PERSON A RECONSIDERATION OF AN ADVERSE
DETERMINATION BY THE REVIEWER MAKING THE ADVERSE DETERMINATION.
THE RECONSIDERATION SHALL OCCUR WITHIN ONE BUSINESS DAY AFTER
RECEIPT OF THE WRITTEN REQUEST, AND SHALL BE CONDUCTED BETWEEN
THE PROVIDER RENDERING THE SERVICE AND THE REVIEWER WHO MADE THE
ADVERSE DETERMINATION. IF THAT REVIEWER CANNOT BE AVAILABLE
WITHIN ONE BUSINESS DAY, THE REVIEWER MAY DESIGNATE ANOTHER REVIEWER.
(B) IF THE
RECONSIDERATION PROCESS DESCRIBED IN DIVISION
(A) OF THIS SECTION DOES NOT
RESOLVE THE DIFFERENCE OF OPINION, THE ADVERSE DETERMINATION MAY
BE APPEALED BY THE COVERED PERSON OR THE PROVIDER ON BEHALF OF
THE COVERED PERSON.
(C) RECONSIDERATION IS
NOT A PREREQUISITE TO A STANDARD OR EXPEDITED APPEAL OF AN
ADVERSE DETERMINATION.
Sec. 1753.72. A HEALTH BENEFIT PLAN THAT IS ACCREDITED BY THE NATIONAL
COMMITTEE ON QUALITY ASSURANCE, THE JOINT COMMISSION ON ACCREDITATION OF
HEALTHCARE ORGANIZATIONS, THE UTILIZATION REVIEW ACCREDITATION COMMISSION, OR
ANY OTHER QUALIFIED ORGANIZATION DESIGNATED IN RULES ADOPTED BY THE
SUPERINTENDENT OF INSURANCE IN ACCORDANCE WITH CHAPTER 119. of the Revised Code, IS
DEEMED TO BE IN COMPLIANCE WITH SECTIONS 1753.66 TO 1753.71 of the Revised Code.
Sec. 1753.73. EACH PROVIDER SHALL COOPERATE WITH THE
UTILIZATION REVIEW PROGRAM OF A HEALTH CARRIER OR UTILIZATION
REVIEW ORGANIZATION AND SHALL PROVIDE THE CARRIER OR ITS
DESIGNEE ACCESS TO AN ENROLLEE'S MEDICAL RECORDS DURING REGULAR
BUSINESS HOURS, OR COPIES OF THOSE RECORDS AT A REASONABLE
COST.
Sec. 1753.75. (A) NO
HEALTH CARRIER SHALL FAIL TO COMPLY WITH SECTIONS 1753.66 TO
1753.71 OF THE REVISED CODE.
(B) WHOEVER VIOLATES
DIVISION (A) OF THIS SECTION IS
DEEMED TO HAVE ENGAGED IN AN UNFAIR AND DECEPTIVE ACT OR
PRACTICE IN THE BUSINESS OF INSURANCE UNDER SECTIONS 3901.19 TO
3901.26 OF THE REVISED CODE.
Sec. 1753.81. NOTHING IN SECTIONS 1753.01 TO 1753.51 OR
1753.66 TO 1753.75 OF THE REVISED CODE SHALL PREVENT OR
OTHERWISE AFFECT THE APPLICATION OF TITLE XXXIX OR ANY OTHER
PROVISION OF TITLE XVII OF THE REVISED
CODE TO ANY HEALTH CARE PLAN TO
WHICH IT WOULD OTHERWISE APPLY.
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