130th Ohio General Assembly
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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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