The online versions of legislation provided on this website are not official. Enrolled bills are the final version passed by the Ohio General Assembly and presented to the Governor for signature. The official version of acts signed by the Governor are available from the Secretary of State's Office in the Continental Plaza, 180 East Broad St., Columbus.
|
***
An attempt was made to recreate these historic documents. The original text was retained, however, during the process some errors in formatting may have been introduced. The official version of the act may be obtained from the Secretary of State's Office listed above.
***
|
(123rd General Assembly)(Amended Substitute House Bill Number 4)
AN ACT
To amend sections 1751.11, 1751.19, 1751.33, 1751.35, 1751.77, 1751.78,
1751.81,
1751.82, 1753.24, and 5747.01; to amend, for the purpose of adopting new
section numbers as indicated in parentheses, sections 1751.83 (1751.821),
1751.84 (1751.822), 1751.85 (1751.823), and 1753.24 (1751.85); and to enact
new sections 1751.83 and 1751.84 and sections 1751.811, 1751.831, 1751.87,
1751.88, 1751.89, 1753.13, 3901.80, 3901.81, 3901.82, 3901.83, 3901.84,
3923.65, 3923.66, 3923.67, 3923.68, 3923.681, 3923.69, 3923.70, 3923.75,
3923.76, 3923.77, 3923.78, and 3923.79 of the Revised Code to
establish
procedures for enrollee appeals of health care coverage decisions by health
insuring corporations, sickness and accident insurers, and state employee
benefit plans and to make other changes in the laws related to health
insuring corporations, sickness and accident insurers, and state employee
benefit plans.
Be it enacted by the General Assembly of the State of Ohio:
SECTION 1 . That sections 1751.11, 1751.19, 1751.33, 1751.35, 1751.77, 1751.78,
1751.81,
1751.82, 1753.24, and 5747.01 be amended, sections 1751.83 (1751.821),
1751.84 (1751.822), 1751.85 (1751.823), and 1753.24 (1751.85) be amended for
the purpose of adopting new section numbers as indicated in parentheses, and
new sections 1751.83 and 1751.84 and sections 1751.811, 1751.831, 1751.87,
1751.88, 1751.89, 1753.13, 3901.80, 3901.81, 3901.82, 3901.83, 3901.84,
3923.65, 3923.66, 3923.67, 3923.68, 3923.681, 3923.69, 3923.70, 3923.75,
3923.76, 3923.77, 3923.78, and 3923.79 of the Revised Code be enacted
to read
as follows:
Sec. 1751.11. (A) Every
subscriber of a health insuring corporation is entitled to an
evidence of coverage for the health care plan under which
health care benefits are
provided. (B) Every subscriber of a health insuring corporation that offers
basic health care services is entitled to an identification card or similar
document that specifies the health insuring corporation's name as stated in
its articles of incorporation, and any trade or fictitious names
used by the health insuring corporation. The identification
card or document shall list at least one toll-free telephone number
that provides the subscriber with access to health care,
to information
on a twenty-four-hours-per-day,
seven-days-per-week basis, as to how health care services may be
obtained. The identification card or document shall also
list at least one toll-free number that, during normal business hours,
provides the subscriber with access to information on the coverage available
under the subscriber's health care plan and information on the health care
plan's internal and external review processes. (C) No evidence of coverage, or amendment to the evidence of
coverage, shall be delivered, issued for delivery, renewed, or used, until the
form of the evidence of coverage or amendment has been filed by the
health insuring corporation with the superintendent of
insurance. If the superintendent does not disapprove the
evidence of coverage or amendment within sixty days after it is
filed it shall be deemed approved, unless the superintendent
sooner gives approval for the evidence of coverage or amendment.
With respect to an amendment to an approved evidence of
coverage, the superintendent only may disapprove provisions
amended or added to the evidence of coverage. If the
superintendent determines within the sixty-day period that any
evidence of coverage or amendment fails to meet the requirements
of this section, the superintendent shall so notify the health
insuring corporation and it shall be unlawful for the health
insuring corporation to use such evidence of coverage or
amendment. At any time, the superintendent, upon at least
thirty days' written notice to a health insuring corporation,
may withdraw an approval, deemed or actual, of any evidence of
coverage or amendment on any of the grounds stated in this
section. Such disapproval shall be effected by a written order,
which shall state the grounds for disapproval and shall be
issued in accordance with
Chapter 119. of the
Revised Code. (D) No evidence of coverage or amendment shall be delivered,
issued for delivery, renewed, or used: (1) If it contains provisions or statements that are
inequitable, untrue, misleading, or deceptive; (2) Unless it contains a clear, concise, and complete
statement of the following: (a) The health care
services and insurance or other benefits, if any, to which the
an
enrollee is entitled under the health care plan; (b) Any exclusions or
limitations on the health care services, type of health care
services, benefits, or type of benefits to be provided,
including copayments; (c) The An enrollee's personal financial obligation for
noncovered
services; (d) Where and in what
manner general information and information as to how health care
services
may be obtained is available, including the a toll-free
telephone
number; (e) The premium rate with respect to individual and
conversion contracts, and relevant copayment provisions with
respect to all contracts. The statement of the premium rate, however, may be
contained in a separate insert. (f) The method utilized
by the health insuring corporation for resolving enrollee
complaints; (g) The utilization review, internal review, and external review
procedures established under
sections 1751.77 to 1751.85 of the
Revised
Code. (3) Unless it provides for the continuation of an
enrollee's coverage, in the event that the enrollee's coverage
under the group policy, contract, certificate, or agreement terminates
while the enrollee is receiving inpatient care in a hospital.
This continuation of coverage shall terminate at the earliest
occurrence of any of the following: (a) The enrollee's discharge from the hospital; (b) The determination by the enrollee's attending physician that
inpatient care is no longer medically indicated for the enrollee;
however, nothing in division
(D)(3)(b)
of this section precludes a health insuring corporation
from engaging in utilization review as described in the evidence
of coverage. (c) The enrollee's reaching the limit for contractual
benefits; (d) The effective date of any new
coverage. (4) Unless it contains a provision that states, in
substance, that the health insuring corporation is not a member
of any guaranty fund, and that in the event of the health
insuring corporation's insolvency, the an enrollee is protected
only to the extent that the hold harmless provision required by
section 1751.13 of the Revised
Code applies to the health care
services rendered; (5) Unless it contains a provision that states, in
substance, that in the event of the insolvency of the health
insuring corporation, the an enrollee may be financially
responsible for health care services rendered by a provider or
health care facility that is not under contract to the health
insuring corporation, whether or not the health insuring
corporation authorized the use of the provider or health care
facility. (E) Notwithstanding
divisions (C) and (D) of this section, a
health insuring corporation may use an evidence of coverage that
provides for the coverage of beneficiaries enrolled in
Title XVIII of the "Social Security
Act," 49 Stat. 620 (1935), 42
U.S.C.A. 301, as amended, pursuant to a
medicare contract, or an evidence of coverage that provides
for the coverage of beneficiaries enrolled in the federal
employees health benefits program pursuant to 5
U.S.C.A.
8905, or an evidence of coverage that provides for the coverage
of beneficiaries enrolled in
Title XIX of the "Social Security
Act," 49 Stat. 620 (1935), 42
U.S.C.A. 301, as amended, known as the
medical assistance program or medicaid, provided
by the Ohio department of human services under Chapter 5111.
of the Revised Code, or an evidence of coverage that
provides for the coverage of beneficiaries under any other federal health care
program regulated by a federal regulatory body,
or an evidence of coverage that provides for the coverage
of beneficiaries under any contract covering officers or
employees of the state that has been entered into
by the department of administrative
services,
if both of the following
apply: (1) The evidence of coverage has been approved by the
United States department of health and
human services, the United States office of personnel
management, the Ohio department of human services, or the
department of administrative services. (2) The evidence of coverage is filed with the
superintendent of insurance prior to use and is accompanied by
documentation of approval from the
United States department of health and
human services, the United States office of personnel
management, the Ohio department of human services, or the
department of administrative services. Sec. 1751.19. (A) A
health insuring corporation shall establish and maintain a
complaint system that has been approved by the superintendent of
insurance to provide adequate and reasonable procedures for the
expeditious resolution of written complaints initiated by
subscribers or enrollees concerning any matter relating to
services provided, directly or indirectly, by the health
insuring corporation, including, but not limited to, claims
complaints regarding the scope of coverage for health care services,
and
denials, cancellations, or nonrenewals of coverage.
Complaints regarding a health insuring corporation's decision
to deny, reduce, or terminate coverage for health care services are subject to
section 1751.83 of the Revised Code. (B) A health insuring
corporation shall provide a timely written response to each
written complaint it receives. Responses to written complaints
relating to quality or appropriateness of care shall set forth a
statement informing the complainant in detail of any rights the
complainant may have to submit such complaint to any
professional peer review organization or health insuring
corporation peer review committee that has been set up to
monitor the quality or appropriateness of provider services
rendered. Such statement shall set forth the name of the peer
review organization or health insuring corporation peer review
committee, its address, telephone number, and any other
pertinent data that will enable the complainant to seek further
independent review of the complaint. Such appeal shall not be
made to the peer review corporation or health insuring
corporation peer review committee until the complaint system of
the health insuring corporation has been exhausted. (C) Copies of complaints
and responses, including medical records related to those
complaints, shall be available to the superintendent and the
director of health for inspection for three years. Any document
or information provided to the superintendent pursuant to this
division that contains a medical record is confidential, and is not a public
record subject to section 149.43 of the Revised Code. (D) A health insuring
corporation shall establish and maintain a procedure to accept
complaints over the telephone or in person. These complaints
are not subject to the reporting requirement under division
(C) of section 1751.32 of the
Revised Code. (E) A health insuring corporation may comply with
this section and section 1751.83 of the Revised Code by
establishing one system for receiving and reviewing complaints and
requests for internal review from enrollees and subscribers if the system
meets the requirements of
both sections. Sec. 1751.33. (A) Each health insuring corporation shall
provide to its subscribers, by mail, a description of the health
insuring corporation, its method of operation, its service area,
its most recent provider list, and its complaint procedure
established pursuant to section 1751.19 of the
Revised Code, and a description of its utilization review, internal
review, and
external review processes established under sections 1751.77 to 1751.85 of the
Revised Code. At the request of or with the approval of the
subscriber, a
health insuring corporation may provide this information by electronic means
rather than by mail.
A health insuring corporation providing
basic health care services or supplemental health care services shall provide
this information annually. A health insuring corporation providing only
specialty health care services shall provide this information biennially. (B) Each health insuring
corporation, upon the request of a subscriber, shall make
available its most recent statutory financial statement. Sec. 1751.35. (A) The
superintendent of insurance may suspend or revoke any
certificate of authority issued to a health insuring corporation
under this chapter if the superintendent finds that: (1) The health insuring corporation is operating in
contravention of its articles of incorporation, its health care
plan or plans, or in a manner contrary to that described in and
reasonably inferred from any other information submitted under
section 1751.03 of the Revised
Code, unless amendments to such
submissions have been filed and have taken effect in compliance
with this chapter. (2) The health insuring corporation fails to issue
evidences of coverage in compliance with the requirements of
section 1751.11 of the Revised
Code. (3) The contractual periodic prepayments or premium rates used
do not comply with the requirements of section 1751.12 of the
Revised Code. (4) The health insuring corporation enters into a
contract, agreement, or other arrangement with any health care
facility or provider, that does not comply with the requirements
of section 1751.13 of the
Revised Code, or the corporation fails
to provide an annual certificate as required by section 1751.13
of the Revised
Code. (5) The director of health has certified, after a hearing
conducted in accordance with Chapter
119. of the Revised Code, that the health insuring
corporation no longer meets the requirements of section 1751.04
of the Revised
Code. (6) The health insuring corporation is no longer
financially responsible and may reasonably be expected to be
unable to meet its obligations to enrollees or prospective
enrollees. (7) The health insuring corporation has failed to
implement the complaint system that complies with the
requirements of section 1751.19 of the
Revised
Code. (8) The health insuring corporation, or any agent or
representative of the corporation, has advertised, merchandised,
or solicited on its behalf in contravention of the requirements
of section 1751.31 of the Revised Code. (9) The health insuring corporation has unlawfully
discriminated against any enrollee or prospective enrollee with
respect to enrollment, disenrollment, or price or quality of
health care services. (10) The continued operation of the health insuring
corporation would be hazardous or otherwise detrimental to its
enrollees. (11) The health insuring corporation has submitted false
information in any filing or submission required under this
chapter or any rule adopted under this chapter. (12) The health insuring corporation has otherwise failed
to substantially comply with this chapter or any rule adopted
under this chapter. (13) The health insuring corporation is not operating a
health care plan. (14) The health insuring corporation has failed to comply with
any of the requirements of sections 1751.77 to 1751.88 of the Revised Code. (B) A certificate of
authority shall be suspended or revoked only after compliance
with the requirements of Chapter 119. of the Revised
Code. (C) When the certificate
of authority of a health insuring corporation is suspended, the
health insuring corporation, during the period of suspension, shall not enroll
any additional subscribers or enrollees except newborn children
or other newly acquired dependents of existing subscribers or
enrollees, and shall not engage in any advertising or
solicitation whatsoever. (D) When the certificate
of authority of a health insuring corporation is revoked, the
health insuring corporation, following the effective date of the order of
revocation, shall conduct no further business except as may be
essential to the orderly conclusion of the affairs of the
health insuring corporation. The health insuring corporation shall engage in
no further
advertising or solicitation whatsoever. The superintendent, by
written order, may permit such further operation of the health insuring
corporation as the superintendent may find to be in the best
interest of enrollees, to the end that enrollees will be
afforded the greatest practical opportunity to obtain continuing
health care coverage. Sec. 1751.77. As used in sections 1751.77 to 1751.86 1751.88
of the Revised Code, unless
otherwise specifically provided: (A) "Adverse determination" means a determination by a health
insuring corporation or its designee utilization review organization that an
admission,
availability of care, continued stay, or other health care service
covered under a policy, contract, or agreement of the health insuring
corporation
has been
reviewed and, based upon the information provided, the health care service
does not meet the health
insuring corporation's requirements for benefit payment under the
health insuring corporation's policy, contract, or agreement, and
coverage is
therefore denied, reduced, or terminated. (B) "Ambulatory review" means utilization review of health care
services performed or provided in an outpatient setting. (C) "Authorized person" means a parent, guardian, or other person
authorized to act on behalf of an enrollee with respect to health care
decisions. (D) "Case management" means a coordinated set of activities
conducted for individual patient management of serious, complicated,
protracted, or other specified health conditions. (D)(E) "Certification" means a determination by a health
insuring
corporation or
its designee utilization review organization that an admission, availability
of care, continued stay, or other health care service
covered under a policy, contract, or agreement of the health insuring
corporation
has been reviewed and,
based upon the information provided, the health care service satisfies the
health insuring corporation's requirements
for benefit payment under the health insuring corporation's policy,
contract, or agreement.
(E)(F) "Clinical peer" means a
physician when an evaluation is to be made of the clinical
appropriateness of health care services provided by a physician.
If an evaluation is to be made of the clinical appropriateness
of health care services provided by a provider who is not a
physician, "clinical peer" means either a physician or a
provider holding the same license as the provider who provided
the health care services.
(F)(G) "Clinical review criteria" means the written screening
procedures, decision abstracts, clinical protocols, and practice guidelines
used by a health insuring corporation to determine the necessity and
appropriateness of
health care services.
(G)(H) "Concurrent review" means utilization review conducted
during a patient's hospital stay or course of treatment.
(H)(I) "Discharge planning" means the formal process for
determining, prior to a patient's discharge from a health care facility, the
coordination and
management of the care that the patient is to receive following discharge from
a health care facility.
(I)(J) "Participating provider" means a provider or health
care facility that, under a
contract with a health insuring corporation or with its contractor or
subcontractor, has
agreed to provide health care services to enrollees with an expectation
of receiving payment, other than coinsurance, copayments, or deductibles,
directly or indirectly from the health insuring corporation.
(J)(K) "Physician" means a provider authorized who
holds a certificate issued under
chapter Chapter 4731. of the
Revised
Code to authorizing the practice of medicine and
surgery or osteopathic medicine and surgery or a comparable license or
certificate from another state.
(K)(L) "Prospective review" means utilization review that is
conducted prior to an admission or a course of treatment.
(L)(M) "Retrospective review" means utilization review of
medical
necessity that is conducted after health care 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.
(M)(N) "Second opinion" means an opportunity or requirement
to
obtain a clinical evaluation by a provider other than the provider originally
making a recommendation for proposed health care services to assess the
clinical necessity and appropriateness of the proposed health care
services.
(N)(O) "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.
(O)(P) "Utilization review organization" means an entity that
conducts utilization review, other than a health insuring corporation
performing a
review of its own health care plans.
Sec. 1751.78. (A)(1) Sections 1751.77 to 1751.86
1751.88 of
the Revised Code apply to any health
insuring corporation that provides or performs utilization review services
in connection with its policies, contracts, and agreements providing
covering
basic health care services and to any designee of the health insuring
corporation,
or to any utilization
review organization that performs utilization review functions
on behalf of the health insuring corporation in connection with policies,
contracts, or agreements of the health insuring corporation providing
covering basic
health care services. (2) Nothing in sections 1751.77 to 1751.82 or section
1751.85 1751.823 of the Revised Code shall be construed to
require a health insuring corporation to provide or perform
utilization review services in connection with health care
services provided under a policy, plan, or agreement of
supplemental health care services or specialty health care
services. (B)(1) Each health
insuring corporation shall be responsible for monitoring all utilization
review and internal review activities carried
out by, or on behalf of, the
health
insuring corporation and for ensuring that all requirements of sections
1751.77 to 1751.86 1751.88 of the Revised Code, and any rules
adopted
thereunder, are met. The health insuring corporation shall also ensure that
appropriate personnel have operational responsibility for the
conduct of the health insuring corporation's utilization review
program. (2) If a health insuring corporation contracts to have a utilization
review organization or other entity perform the utilization
review functions required by sections 1751.77 to 1751.86
1751.88 of the
Revised Code, and any rules adopted
thereunder, the superintendent of insurance shall hold the
health insuring corporation 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. 1751.81. (A) As used in this section: (1) "Enrollee" includes the representative of an enrollee.
(2) "Necessary, "Necessary information" includes
the
results of any face-to-face
clinical
evaluation or second opinion that may be required.
(B) A health insuring corporation shall maintain written
procedures for determining whether a requested service is a service covered
under the terms of an enrollee's policy, contract, or agreement,
making
utilization review determinations, and for notifying enrollees,
and participating providers, and
health care facilities
acting on behalf of enrollees, of its determinations. (C) For initial prospective review
determinations, a health insuring corporation
shall make the
determination within two business days after obtaining all necessary
information
regarding a proposed admission, procedure, or health care service requiring a
review
determination. (1) In the case of a determination to certify an admission, procedure, or
health care service, the health insuring corporation shall notify the provider
or health care facility rendering the health care service by
telephone or facsimile within three business days after making the
initial certification. (2) In the case of an adverse determination, the health insuring
corporation shall notify the
provider or health care facility rendering the health care service by
telephone within three business days after making
the adverse determination, and shall provide written or electronic
confirmation of the telephone notification to the enrollee and the
provider or health care facility within one business day after making the
telephone notification. (D) For concurrent review determinations, a health
insuring
corporation shall
make the determination within one business day after obtaining all necessary
information. (1) In the case of a determination to certify an extended stay or
additional health care services, the health insuring corporation shall notify
the provider or health care facility
rendering the health care service by telephone or facsimile within one
business day after
making the certification. (2) In the case of an adverse determination, the health insuring
corporation shall notify the provider or health care facility rendering the
health care service by telephone within one business day after
making the adverse determination, and shall provide written or electronic
confirmation to the enrollee and the provider or health care facility
within one business day after
the telephone notification. The health care service to the enrollee shall be
continued, with
standard copayments and deductibles, if applicable, until the enrollee has
been notified of the
determination. (E) For retrospective review determinations, a health
insuring
corporation
shall make
the determination within thirty business days after receiving all necessary
information. (1) In the case of a certification, the health insuring corporation may
notify the
enrollee and the provider or health care facility rendering the health care
service in writing. (2) In the case of an adverse determination, the health insuring
corporation shall notify
the enrollee and the provider or health care facility rendering the health
care service, in writing, within five
business days after making the adverse determination. (F)(1) The time frames set forth in divisions (C),
(D), and (E) of this section for
determinations and
notifications shall prevail unless the seriousness of the medical condition of
the enrollee otherwise requires a more timely response from the health
insuring corporation. The health insuring corporation shall maintain written
procedures for
making expedited utilization review determinations and notifications of
enrollees and
providers or health care facilities when warranted by the medical condition
of the enrollee. (2) An enrollee, an authorized person, the enrollee's provider,
or the health care facility rendering health care service to an enrollee may
proceed with a request
for an internal review
pursuant to section 1751.83 of the
Revised
Code if a health insuring
corporation fails to make a determination and notification
within the time frames set forth in division (C),
(D), or (E) of this section. The
ENROLLEE MAY
REQUEST A REVIEW WITHOUT THE APPROVAL OF THE PROVIDER OR THE
HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE. THE
PROVIDER OR HEALTH CARE FACILITY MAY NOT REQUEST A REVIEW WITHOUT
THE PRIOR CONSENT OF THE ENROLLEE. The
health insuring corporation's failure to make a determination
and notification within the time frames set forth in division (C),
(D), or (E) of this section shall be deemed to be
an adverse determination by the health insuring corporation for
the purpose of initiating an internal review. (G) A written notification of an adverse determination
shall include the principal reason or reasons for the determination,
instructions
for initiating an appeal or a reconsideration
of the determination under section 1751.82 of the Revised
Code or an internal review under section 1751.83 of the
Revised Code, and
instructions for requesting a written statement of the clinical rationale
used to make the determination. A health insuring corporation shall provide
the clinical
rationale for an adverse determination in writing
to any party who received
notice of the adverse determination and who follows the instructions for a
request. (H)(1) A health insuring corporation shall have written
procedures to address the
failure or inability of a health care facility, provider, or enrollee to
provide all necessary information for review. (2) A health insuring corporation shall not use
unreasonable requests for information to delay making a
determination. (3) If the health care facility, provider, or
enrollee will not
release necessary information, the health insuring corporation may deny
certification. An enrollee need not be granted an internal review
pursuant to section 1751.83 of the Revised
Code based on a health
insuring corporation's failure to make a timely determination,
if the health insuring corporation's delay in making a
determination and notification is caused by the failure of a
health care facility, provider, or enrollee to release all
necessary information, in which case the health insuring corporation shall
notify the enrollee in writing of the reason for the delay. Sec. 1751.811. In lieu of conducting a prospective, concurrent,
or retrospective review under section 1751.81 of the Revised
Code,
providing a reconsideration under section 1751.82 of the Revised
Code, or conducting an internal review
under section 1751.83 of the Revised Code, a health
insuring corporation may afford an enrollee an opportunity for an
external review under section 1751.84 or 1751.85 of the
Revised Code. If an external
review is conducted pursuant to this section, the health insuring corporation
is not required to
afford the enrollee an opportunity for any of the reviews that were
disregarded pursuant to this
section, including the external review that may have resulted from
a review that was disregarded pursuant to this section, unless new
clinical information is submitted to the health insuring
corporation. Sec. 1751.82. (A) In a
case involving an initial a prospective determination or a
concurrent review
determination, a health insuring corporation shall give the provider or health
care facility
rendering the health care service an opportunity to request in writing on
behalf of the enrollee a reconsideration of an adverse
determination by the reviewer making the adverse determination.
The provider or health care facility may not request a reconsideration
without the prior consent of the enrollee. The reconsideration
shall occur within three business days after
the health insuring corporation's receipt of the written request for
reconsideration, and shall be conducted between
the provider or health care facility rendering the health care service and the
reviewer who made the
adverse determination. If that reviewer cannot be available
within three business days, 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 enrollee, an authorized person, or
the provider or health care facility acting on behalf
of the enrollee may request an internal review under section 1751.83
of the Revised Code. The provider or health care facility may not request an internal review
without the prior consent of the enrollee. (C) Reconsideration is not a prerequisite to a standard an
internal or
expedited appeal external review of an adverse determination. (D) The time period
allowed by division (A) of this section for a
reconsideration of an adverse determination shall not apply if
the seriousness of the medical condition of the enrollee
requires a more expedited reconsideration. The health insuring
corporation shall maintain written procedures for making such an
expedited reconsideration. Sec. 1751.83 1751.821. A health insuring
corporation may present evidence of compliance with the
requirements of sections 1751.77 to 1751.82 of the Revised Code by submitting
evidence
to the superintendent of insurance of its accreditation by an independent,
private accrediting organization, such as the national committee
on quality assurance, the national quality health council, the joint
commission on accreditation of
health care organizations, or the American accreditation healthcare
commission/utilization review
accreditation commission. The superintendent, upon review of
the organization's accreditation process, may determine that
such accreditation constitutes compliance by the health insuring
corporation with the requirements of these sections. Sec. 1751.84 1751.822. Each participating provider or health
care facility
submitting a claim shall cooperate with the
utilization review program of a health insuring corporation or utilization
review organization and shall provide the health insuring corporation or its
designee access to an enrollee's medical records during regular
business hours, or copies of those records at a reasonable
cost. Sec. 1751.85 1751.823. A health insuring corporation shall
annually file a
certificate with the superintendent of insurance certifying its
compliance with sections 1751.77 to 1751.82 of the
Revised
Code. Sec. 1751.83. A health insuring corporation shall establish and maintain
an internal review system that has been approved by the superintendent of
insurance. The system shall provide for review by a clinical peer and include
adequate and reasonable procedures for review and resolution of appeals from
enrollees concerning
adverse
determinations made under section 1751.81 of the Revised Code, including procedures for
verifying and reviewing appeals from enrollees whose medical conditions
require expedited review. A health insuring corporation shall consider and provide a written
response to each request for an internal review
NOT LATER
THAN SIXTY DAYS AFTER RECEIPT OF THE REQUEST, EXCEPT THAT IF THE
SERIOUSNESS OF THE ENROLLEE'S MEDICAL CONDITION REQUIRES AN
EXPEDITED REVIEW, THE HEALTH INSURING CORPORATION SHALL PROVIDE
THE WRITTEN RESPONSE NOT LATER THAN SEVEN DAYS AFTER RECEIPT OF
THE REQUEST.
The response shall state the
reason for
the health insuring corporation's decision, inform the enrollee of the right
to pursue a further review, and explain the
procedures for initiating the review, including the time frames
within which the enrollee must request the review, as specified in
section 1751.84 or 1751.85 of the Revised Code. Failure by
a health insuring corporation to provide a written response within
the time frames specified under this section shall be deemed a denial
by the health insuring corporation for purposes of requesting a
review under section 1751.831, 1751.84, or 1751.85 of the Revised
Code. If the health
insuring
corporation has denied, reduced, or terminated coverage for a health care
service on the grounds that the service is not a service covered under the
terms of the
enrollee's policy, contract, or agreement, the response shall
inform the enrollee of the right to request a review by the
superintendent of insurance under section 1751.831 of the Revised
Code. If the health insuring corporation has denied, reduced, or
terminated coverage for a health care service on the grounds that the
service is not medically necessary, the response
shall inform the
enrollee of the right to request an external review under section
1751.84 of the Revised Code, except that if
the enrollee meets the criteria set forth in
division (A) of section 1751.85 of the Revised Code, the response
shall inform the enrollee of the right to request an external review
under section 1751.85 of the Revised Code. The health insuring corporation shall make available to the
superintendent for inspection copies of all documents in the health insuring
corporation's possession related to reviews
conducted pursuant to this section, including medical records related to those
reviews, and of responses, for three years following
completion of the review. Sec. 1751.831. THE SUPERINTENDENT OF INSURANCE SHALL ESTABLISH
AND MAINTAIN A SYSTEM FOR RECEIVING AND REVIEWING REQUESTS FOR REVIEW
FROM OR ON BEHALF OF ENROLLEES WHO, UNDER SECTION 1751.83
of the Revised Code, HAVE BEEN DENIED COVERAGE OF A HEALTH CARE SERVICE
OR HAD COVERAGE REDUCED OR TERMINATED when the grounds for the
denial, reduction, or termination is that THE SERVICE IS NOT A
SERVICE COVERED UNDER THE TERMS OF THE ENROLLEE'S POLICY,
CONTRACT, OR AGREEMENT. On receipt of a written request from an enrollee or authorized person, the
superintendent shall consider whether the health care service is a service
covered
under the terms of the enrollee's policy, contract, or agreement, except
that the superintendent shall not conduct a review
under this section unless the enrollee has exhausted the health
insuring corporation's internal review process established pursuant to section
1751.83 of the Revised Code. The health insuring corporation and
the enrollee or authorized person shall provide the superintendent with any
information required by the
superintendent that is in their possession and is germane to the review. Unless the superintendent is not able to do so because making the
determination requires resolution of a medical issue, the superintendent shall
determine whether the health care service at issue is a service covered
under the terms of the enrollee's contract, policy, or agreement.
The superintendent shall notify the enrollee and the health
insuring corporation of the superintendent's determination or that the
superintendent is not able
to make a determination. If the superintendent notifies the health insuring corporation
that making the determination requires the resolution of a medical
issue, the health insuring corporation shall afford the enrollee
an opportunity for external review under section 1751.84 or 1751.85 of the Revised Code. If
the superintendent notifies the health insuring corporation that
the health service is a covered service, the health insuring corporation
shall either cover the service or afford the enrollee an opportunity for an
external review under section 1751.84 or 1751.85 of the Revised Code. if the superintendent
notifies the health insuring corporation that the health care service
is not a covered service, the health insuring corporation is not required to
cover the service or afford the enrollee an
external review. Sec. 1751.84. (A) EXCEPT AS PROVIDED IN DIVISIONs (B)
and (C) OF
THIS
SECTION, A HEALTH INSURING CORPORATION SHALL afford AN ENROLLEE AN opportunity
for an EXTERNAL REVIEW if both of the following are the case: (1) The HEALTH INSURING CORPORATION HAS DENIED, reduced,
or
terminated
COVERAGE FOR WHAT WOULD BE A COVERED HEALTH CARE SERVICE EXCEPT
FOR THE FACT THAT THE HEALTH INSURING CORPORATION HAS DETERMINED
THAT THE HEALTH CARE SERVICE IS NOT MEDICALLY NECESSARY; (2) Except in the case of an expedited review, the service, plus any
ancillary services and follow-up care,
will cost the enrollee more than five hundred dollars if the proposed service
is not covered by the health insuring corporation. EXTERNAL REVIEW SHALL BE conducted IN ACCORDANCE WITH THIS SECTION,
EXCEPT THAT IF AN ENROLLEE WITH A TERMINAL CONDITION MEETS ALL OF
THE CRITERIA OF DIVISION (A) OF SECTION 1751.85 OF THE
REVISED
CODE, AN EXTERNAL REVIEW SHALL BE CONDUCTED UNDER THAT SECTION. (B) AN ENROLLEE need NOT BE AFFORDED A REVIEW UNDER THIS SECTION
IN any OF THE FOLLOWING CIRCUMSTANCES: (1) The superintendent of insurance has DETERMINED UNDER SECTION 1751.831
OF THE REVISED CODE
THAT THE HEALTH CARE SERVICE IS NOT a service COVERED UNDER THE TERMS OF THE
ENROLLEE'S
POLICY, CONTRACT, OR AGREEMENT. (2) Except as provided in section 1751.811 of the Revised Code, THE ENROLLEE HAS FAILED
TO EXHAUST THE HEALTH INSURING
CORPORATION'S INTERNAL review PROCESS ESTABLISHED pursuant to SECTION
1751.83 OF THE REVISED CODE. (3) The enrollee has previously been afforded an external review for the
same adverse determination and no new clinical information has been submitted
to the health insuring corporation. (C)(1) A health insuring corporation may deny a request for an
EXTERNAL REVIEW OF
AN ADVERSE DETERMINATION if it is
REQUESTED LATER THAN sixty DAYS AFTER THE enrollee's receipt of NOTICE
of the result of an
INTERNAL review brought UNDER SECTION 1751.83 OF THE REVISED
CODE.
An external REVIEW MAY BE REQUESTED BY THE ENROLLEE, an authorized person, THE
ENROLLEE'S
PROVIDER, OR A HEALTH CARE FACILITY
RENDERING HEALTH CARE SERVICE TO THE ENROLLEE. THE ENROLLEE MAY
REQUEST A REVIEW WITHOUT THE APPROVAL OF THE PROVIDER OR THE
HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE. THE
PROVIDER OR HEALTH CARE FACILITY MAY NOT REQUEST A REVIEW WITHOUT
THE prior CONSENT OF THE ENROLLEE. (2) AN EXTERNAL REVIEW MUST BE REQUESTED IN WRITING, EXCEPT THAT
IF THE ENROLLEE HAS A CONDITION THAT REQUIRES EXPEDITED REVIEW,
THE REVIEW MAY BE REQUESTED ORALLY OR BY ELECTRONIC MEANS. When an oral or
electronic request for review is made, written confirmation
of the
request shall be submitted to the health insuring corporation not
later than five days after the oral or written request is
submitted. Except in the case of an expedited review, a request for an external review
must be accompanied by written
certification from the enrollee's provider or the health care facility
rendering the health care service to the enrollee that the proposed service,
plus any ancillary services and follow-up care, will cost the enrollee more
than five hundred dollars if the proposed service is not covered by the health
insuring corporation. (3) FOR AN EXPEDITED REVIEW, THE ENROLLEE'S PROVIDER MUST CERTIFY
THAT THE ENROLLEE'S CONDITION COULD, in the absence of immediate medical
attention, RESULT IN ANY OF THE
FOLLOWING: (a) PLACING THE HEALTH OF THE ENROLLEE OR, WITH RESPECT TO A
PREGNANT WOMAN, THE HEALTH OF the ENROLLEE or the UNBORN CHILD, IN SERIOUS
JEOPARDY; (b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; (c) SERIOUS DYSFUNCTION of ANY BODILY ORGAN OR PART. (D) THE PROCEDURES USED IN CONDUCTING AN EXTERNAL REVIEW OF AN
ADVERSE DETERMINATION SHALL INCLUDE ALL OF THE FOLLOWING: (1) THE REVIEW SHALL BE CONDUCTED BY an INDEPENDENT review organization
assigned by the superintendent of insurance under
section 3901.80 of the Revised Code. (2) EXCEPT AS PROVIDED IN DIVISION (D)(3) AND (4) OF THIS
SECTION,
NEITHER THE CLINICAL PEER NOR ANY HEALTH CARE FACILITY WITH WHICH THE CLINICAL
PEER IS
AFFILIATED SHALL HAVE ANY PROFESSIONAL, FAMILIAL, OR FINANCIAL
AFFILIATION WITH ANY OF THE FOLLOWING: (a) THE HEALTH INSURING CORPORATION OR ANY OFFICER, DIRECTOR, OR
MANAGERIAL EMPLOYEE OF THE HEALTH INSURING CORPORATION; (b) THE ENROLLEE, THE ENROLLEE'S PROVIDER, OR THE PRACTICE GROUP
OF THE ENROLLEE'S PROVIDER; (c) THE HEALTH CARE FACILITY AT WHICH THE HEALTH CARE SERVICE
REQUESTED BY THE ENROLLEE WOULD BE PROVIDED; (d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, DEVICE,
PROCEDURE, OR THERAPY PROPOSED FOR THE ENROLLEE. (3) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT A CLINICAL
PEER FROM CONDUCTING A REVIEW UNDER any of THE FOLLOWING CIRCUMSTANCES: (a) THE CLINICAL PEER IS AFFILIATED WITH AN ACADEMIC MEDICAL
CENTER THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF THE HEALTH INSURING
CORPORATION. (b) THE CLINICAL PEER HAS STAFF PRIVILEGES AT A HEALTH CARE
FACILITY THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF THE HEALTH
INSURING CORPORATION. (c) THE CLINICAL PEER IS A PARTICIPATING PROVIDER BUT WAS NOT
INVOLVED WITH THE HEALTH INSURING CORPORATION'S ADVERSE DETERMINATION. (4) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT THE HEALTH
INSURING CORPORATION FROM PAYING THE INDEPENDENT REVIEW ORGANIZATION FOR THE
CONDUCT OF THE REVIEW. (5) AN ENROLLEE SHALL NOT BE REQUIRED TO PAY FOR ANY PART OF THE
COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE BY THE
HEALTH INSURING CORPORATION. (6)(a) THE HEALTH INSURING CORPORATION
SHALL PROVIDE TO THE
INDEPENDENT REVIEW ORGANIZATION CONDUCTING THE REVIEW A COPY OF THOSE RECORDS
IN its POSSESSION THAT ARE RELEVANT TO THE ENROLLEE'S MEDICAL
CONDITION AND THE REVIEW. THE RECORDS SHALL BE USED SOLELY FOR
THE PURPOSE OF THIS DIVISION. AT THE REQUEST OF THE INDEPENDENT
REVIEW ORGANIZATION, THE HEALTH INSURING CORPORATION, ENROLLEE, OR THE
PROVIDER OR HEALTH
CARE FACILITY RENDERING HEALTH CARE SERVICES TO THE ENROLLEE SHALL
PROVIDE ANY ADDITIONAL INFORMATION THE INDEPENDENT review organization
requests TO COMPLETE the REVIEW.
A request for additional information may be made in writing, orally, or by
electronic means. the
independent review organization shall submit the request to the enrollee
and health insuring corporation. If a request is submitted orally or by
electronic means to an enrollee or health insuring corporation,
not later than five days after the request is submitted, the
independent review organization shall provide written confirmation
of the request. If the review was initiated by a provider or
health care facility, a copy of the request shall be submitted to
the provider or health care facility. (b) AN INDEPENDENT review organization IS NOT REQUIRED TO MAKE A
DECISION IF IT HAS NOT RECEIVED ANY REQUESTED INFORMATION THAT IT CONSIDERS
NECESSARY TO
COMPLETE A REVIEW. An independent review
organization that does not make a decision for this reason shall notify
the enrollee and the health insuring corporation that a decision
is not being made. The notice may be made in writing, orally, or
by electronic means. An Oral or electronic notice shall be
confirmed in writing not later than five days after the oral or
electronic notice is made. If the review was initiated by a
provider or health care facility, a copy of the notice shall be
submitted to the provider or health care facility. (7) THE HEALTH
INSURING CORPORATION MAY ELECT TO COVER THE SERVICE REQUESTED AND
TERMINATE THE REVIEW. THE HEALTH INSURING CORPORATION SHALL
NOTIFY the enrollee and ALL other PARTIES INVOLVED WITH THE DECISION BY
mail or, with the consent or approval of the enrollee, by electronic means. (8) IN MAKING ITS DECISION, AN INDEPENDENT review organization CONDUCTING
THE REVIEW SHALL TAKE INTO ACCOUNT all of THE FOLLOWING: (a) INFORMATION SUBMITTED BY THE HEALTH INSURING CORPORATION, THE
ENROLLEE, THE ENROLLEE'S PROVIDER, and THE HEALTH CARE FACILITY RENDERING THE
HEALTH CARE
SERVICE, INCLUDING THE FOLLOWING: (i) THE ENROLLEE'S MEDICAL RECORDS; (ii) THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED BY THE
HEALTH INSURING CORPORATION TO MAKE ITS DECISION. (b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT DOCUMENTS OF
GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED ORGANIZATIONS, INCLUDING THE
NATIONAL INSTITUTES
OF HEALTH OR ANY BOARD RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH, THE
NATIONAL CANCER
INSTITUTE, THE NATIONAL
ACADEMY OF SCIENCES, THE UNITED STATES
FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE FINANCING
ADMINISTRATION OF THE UNITED STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, AND THE AGENCY FOR HEALTH CARE POLICY AND
RESEARCH; (c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR SCIENTIFIC
LITERATURE, PUBLISHED OPINIONS OF NATIONALLY RECOGNIZED MEDICAL experts, and
clinical guidelines adopted by relevant national
MEDICAL SOCIETIES. (9)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT review
organization SHALL ISSUE A WRITTEN DECISION NOT LATER THAN SEVEN DAYS AFTER
the FILING of
THE
REQUEST FOR REVIEW.
IN ALL OTHER CASES, THE INDEPENDENT review organization SHALL ISSUE A WRITTEN
DECISION NOT
LATER THAN THIRTY
DAYS AFTER THE FILING OF THE REQUEST. THE INDEPENDENT review organization
SHALL SEND A COPY OF ITS DECISION TO THE HEALTH INSURING
CORPORATION AND THE ENROLLEE. IF THE ENROLLEE'S PROVIDER OR THE
HEALTH CARE FACILITY RENDERING HEALTH CARE SERVICES TO THE
ENROLLEE REQUESTED THE review, THE INDEPENDENT review organization SHALL also
SEND A
COPY OF ITS DECISION TO THE ENROLLEE'S PROVIDER OR THE HEALTH CARE
fACILITY. (b) THE INDEPENDENT review organization's decision SHALL INCLUDE
A DESCRIPTION
OF THE ENROLLEE'S CONDITION AND THE PRINCIPAL REASONS FOR THE DECISION AND AN
EXPLANATION OF THE
CLINICAL RATIONALE FOR THE DECISION. (E) The independent review organization shall base its decision
on the information submitted under division (D)(8) of this section.
In making its decision, the independent review organization shall consider
safety, efficacy, appropriateness, and cost effectiveness. (F) THE HEALTH INSURING CORPORATION SHALL PROVIDE ANY COVERAGE
determined BY THE INDEPENDENT review organization's DECISION to be medically
necessary, subject to the other terms,
limitations, and conditions of the enrollee's contract. The decision shall
apply only to the individual enrollee's external review. Sec. 1753.24 1751.85. (A) Each health insuring corporation
shall
establish a
reasonable external, independent review process to examine the health insuring
corporation's coverage
decisions for 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 REQUESTS A REVIEW
NOT LATER THAN SIXTY DAYS AFTER RECEIPT BY THE ENROLLEE OF NOTICE
OF THE RESULT OF AN INTERNAL REVIEW UNDER SECTION 1751.83 OF THE
REVISED CODE. (3) The enrollee's physician certifies that the enrollee has the
condition
described in division (A)(1) of this section
and any of the following situations are applicable: (a) Standard therapies have not been effective in improving the
condition of the
enrollee; (b) Standard therapies are not medically appropriate
for the enrollee; (c) There is no standard therapy
covered by the health insuring corporation that is more beneficial than
therapy described in division (A)(3)(4) of
this section. (3)(4) The enrollee's physician has recommended a drug,
device, procedure, or
other therapy that the physician certifies, in writing,
is likely to be more beneficial to the enrollee, in the physician's opinion,
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)(5) The enrollee has been denied coverage by the health
insuring
corporation for a drug,
device,
procedure, or other therapy recommended or requested pursuant to division
(A)(3)(4) of this section, and has exhausted all the
health insuring corporation's internal
appeals review process established pursuant to section 1751.83 of
the
Revised Code.
(5)(6) The drug, device, procedure, or other therapy,
recommended or
requested pursuant to
division (A)(3) of this section,
for which coverage has been denied would be a covered health care
service except
for the health insuring corporation's determination that the drug, device,
procedure, or other
therapy is experimental or investigational.
(B) A review shall be requested in writing, except that if the
enrollee's physician determines that a therapy would be significantly
less effective if not promptly initiated, the review may be requested
orally or by electronic means. When an oral or electronic request for review
is made, written confirmation of the request shall be submitted to the health
insuring corporation not later than five days after the oral or written
request is submitted. (C)
The external, independent review process established by a
health insuring corporation shall meet all of the following criteria: (1) Except as provided in division (C)(E) of this section,
the
process shall offer afford all enrollees who meet the criteria
set forth
in division (A) of this section the opportunity to have
the health insuring corporation's decision to deny
coverage of the recommended or requested
therapy reviewed under the process. Each eligible enrollee shall be
notified
of that opportunity within five business days after the
health insuring corporation denies coverage. (2) The review of the health insuring corporation's decision shall
be conducted by experts selected by an independent entity
that
has been retained by the health insuring corporation for this
purpose. The independent
entity shall be
either an academic
medical center or an entity that has as its
primary function,
and that receives a majority of its revenue from, the provision
of expert reviews and related services review organization assigned by
the superintendent of insurance under
section 3901.80 of the Revised Code. The independent entity review organization shall select a panel
to conduct
the review, which panel shall be composed
of at least three physicians or other
providers who, through clinical experience in the past three
years, are experts in the treatment of the enrollee's medical
condition
and knowledgeable about the recommended or requested therapy. If the
independent entity
retained by the health insuring
corporation is an academic medical center, the panel may include
experts affiliated with or employed by the academic medical
center. In either of the following circumstances, an exception
may be made to the requirement that the review be conducted by
an expert panel composed of a minimum of three physicians or
other providers: (a) A review may be conducted by
an expert panel composed of only two physicians or other
providers if an enrollee has consented in writing to a review by
the smaller panel; (b) A review may be conducted by a
single expert physician or other provider if only one expert
physician or other provider is available for the review. (3) Neither the health insuring corporation nor the enrollee shall choose,
or control the choice of,
the physician or other provider experts. (4) Neither the The selected experts nor, any
health care facility with which an expert is affiliated, and the
independent entity review organization arranging for the
experts' review, shall not have any professional, familial, or
financial affiliation with the any of the following: (a) The health insuring corporation, except that
or any officer, director, or managerial employee of the health insuring
corporation; (b) The enrollee, the enrollee's physician, or the practice group
of the enrollee's physician; (c) The health care facility at which the recommended or
requested therapy would be provided; (d) The development or manufacture of the PRINCIPAL drug,
device, procedure, or therapy involved in the recommended or requested
therapy. However,
experts affiliated with academic medical centers
who provide healthcare health care services to enrollees of the
health insuring
corporation may serve as experts on the review
panel. This
Further, experts with staff privileges at a health care facility
that provides health care services to enrollees of the health insuring
corporation, as well as experts who are participating providers, but who
were not involved with the health insuring corporation's denial of
coverage for the therapy under review, may serve as experts on the
review panel. These
nonaffiliation provision does provisions do not
preclude a health insuring corporation from paying for the experts' review, as
specified in
division (B)(C)(5) of this section. The experts shall have
no
patient-physician relationship or other affiliation with an enrollee whose
request for therapy is under review or with a provider whose recommendation
for therapy is under review. (5) Enrollees shall not be required to pay for any part of the
external, independent cost of the
review. The costs cost of the review shall be borne by the
health insuring
corporation. (6) The health insuring corporation shall provide to the independent
entity review organization arranging for the experts'
review and to the enrollee and the enrollee's physician a copy of those
medical records in the health insuring corporation's possession that
are
relevant to the enrollee's medical
condition for which
therapy has been recommended or requested and the review. The
medical records shall be
disclosed solely
to the expert reviewers and shall be used solely for the purpose of this
section.
AT THE REQUEST OF THE EXPERT REVIEWERS, THE HEALTH INSURING
CORPORATION OR THE PHYSICIAN RECOMMENDING THE THERAPY SHALL
PROVIDE ANY ADDITIONAL INFORMATION THAT THE EXPERT REVIEWERS
REQUEST TO COMPLETE THE REVIEW. AN EXPERT REVIEWER IS NOT
REQUIRED TO RENDER AN OPINION IF THE REVIEWER HAS NOT RECEIVED ANY
REQUESTED INFORMATION THAT THE REVIEWER CONSIDERS NECESSARY TO
COMPLETE THE REVIEW. (7)(a) The opinions of the experts on the panel shall be rendered
within
thirty
days after the enrollee's request for review. If the enrollee's physician
determines
that a therapy would be significantly less effective if not
promptly initiated, the opinions shall be rendered within seven days after the
enrollee's request for review. (b) In conducting the review, the experts on the panel
shall take
into account all of the following: (i) Information submitted by the health insuring corporation,
the enrollee, and the enrollee's physician, including the enrollee's medical
records and the standards, criteria, and
clinical rationale used by the health insuring corporation to
reach its coverage decision; (ii) Findings, studies, research, and other relevant documents of
government agencies and nationally recognized organizations; (iii) Relevant findings in peer-reviewed medical or scientific
literature and published opinions of nationally recognized medical
experts; (iv) Clinical guidelines adopted by relevant national medical
societies; (v) SAFETY, EFFICACY, APPROPRIATENESS, AND COST EFFECTIVENESS. (8) Each expert on the panel shall provide the independent entity
review organization with a
professional opinion as to whether there is sufficient evidence to demonstrate
that the recommended or requested therapy is likely to be more beneficial to
the enrollee than
standard therapies. (9) Each expert's opinion shall be presented in written form and shall
include the
following information: (a) A description of the enrollee's condition; (b) A description of the indicators relevant to determining
whether there is sufficient evidence to demonstrate that the recommended or
requested 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
recommended or requested therapy according to a treatment protocol in a
clinical trial, if
applicable. (10) The independent entity review organization shall provide
the health insuring corporation
with the opinions of the
experts. The health insuring corporation shall make the experts' opinions
available to the enrollee
and the enrollee's physician, upon request. (11) The decision opinion of the majority of the experts on the
panel, rendered
pursuant to division (B)(C)(8) of this section, is binding on
the health
insuring corporation with respect to that enrollee.
If the opinions of the experts on the panel are evenly divided as to whether
the therapy should be covered, then the health insuring corporation'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 health insuring corporation may, in its
discretion, cover the therapy.
However, any coverage provided pursuant to division (B)(C)(11)
of this
section is subject to the terms, limitations, and
conditions of the enrollee's contract with
the health insuring corporation. (12) The health insuring corporation shall have written policies
describing the external, independent
review process. The health insuring corporation shall disclose the
availability of the external,
independent review process in the health insuring corporation's evidence of
coverage and disclosure
forms. (C)(D)
AT ANY TIME DURING THE EXTERNAL, INDEPENDENT REVIEW PROCESS, THE
HEALTH INSURING CORPORATION MAY ELECT TO COVER THE RECOMMENDED OR
REQUESTED HEALTH CARE SERVICE AND TERMINATE THE REVIEW. THE
HEALTH INSURING CORPORATION SHALL NOTIFY THE ENROLLEE AND ALL
OTHER PARTIES INVOLVED BY MAIL OR, WITH THE CONSENT OR APPROVAL OF
THE ENROLLEE, BY ELECTRONIC MEANS.
(E) If a health insuring corporation's initial denial of coverage
for a therapy recommended or requested pursuant to division
(A)(3)(4) of this section is based upon an external,
independent review of that therapy meeting the requirements of
division (B)(C) of this section, this section shall not be a
basis for requiring a second external, independent review of the
recommended or requested therapy. (D)(F) The health insuring corporation shall annually file a
certificate with the superintendent of insurance certifying its
compliance with the requirements of this section.
Sec. 1751.87. Nothing in sections 1751.77 to 1751.85 of the Revised Code shall be
construed to create a cause of action against any of the following: (A) An employer that provides
health care benefits to employees through a health insuring corporation; (B) A clinical peer, medical expert, or independent review
organization that
participates in an
external review under section 1751.84 or 1751.85 of the Revised Code; (C) A health insuring
corporation that provides coverage for benefits in accordance with division
(F) of section 1751.84 or division (C)(11) of section
1751.85
of the Revised Code. Sec. 1751.88. CONSISTENT WITH THE RULES OF
EVIDENCE, A WRITTEN
DECISION OR OPINION PREPARED BY or for AN INDEPENDENT review organization
UNDER SECTION 1751.84 OR
1751.85 OF THE REVISED CODE SHALL BE ADMISSIBLE IN ANY CIVIL
ACTION RELATED TO THE COVERAGE DECISION THAT WAS THE SUBJECT OF THE decision
or OPINION.
THE INDEPENDENT review organization's DECISION OR OPINION SHALL BE PRESUMED TO
BE A
SCIENTIFICALLY
VALID AND ACCURATE DESCRIPTION OF THE STATE OF MEDICAL KNOWLEDGE AT THE TIME
IT WAS WRITTEN. CONSISTENT WITH THE RULES OF EVIDENCE, ANY PARTY TO A CIVIL
ACTION RELATED TO A HEALTH INSURING CORPORATION'S COVERAGE DECISION INVOLVING
AN INVESTIGATIONAL OR
EXPERIMENTAL DRUG, DEVICE, OR TREATMENT MAY INTRODUCE INTO
EVIDENCE ANY APPLICABLE MEDICARE REIMBURSEMENT STANDARDS
ESTABLISHED UNDER TITLE XVIII OF THE "SOCIAL
SECURITY ACT," 49
STAT. 620(1935), 42 U.S.C.A301,
AS AMENDED. Sec. 1751.89. Sections 1751.77 to 1751.85 of the Revised
Code do not apply to either of the following: (A) Coverage provided to beneficiaries enrolled in the
medicare+choice program operated under Title XVIII of the
"Social Security Act," 49 Stat. 620
(1935), 42 U.S.C.A. 301, as amended; (B) Coverage provided to recipients of assistance under the
medicaid program operated pursuant to Chapter 5111. of the
Revised Code. Sec. 1753.13. EVERY INDIVIDUAL OR GROUP HEALTH INSURING
CORPORATION POLICY, CONTRACT, OR AGREEMENT THAT PROVIDES BASIC
HEALTH CARE SERVICES BUT DOES NOT ALLOW DIRECT ACCESS TO
OBSTETRICIANS OR GYNECOLOGISTS SHALL PERMIT A FEMALE ENROLLEE TO
OBTAIN covered OBSTETRIC AND GYNECOLOGICAL SERVICES FROM A participating
OBSTETRICIAN
OR GYNECOLOGIST WITHOUT OBTAINING A REFERRAL FROM THE ENROLLEE'S
PRIMARY CARE PROVIDER. NO INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION POLICY,
CONTRACT, OR AGREEMENT MAY LIMIT THE NUMBER OF ALLOWABLE VISITS TO
A participating OBSTETRICIAN OR GYNECOLOGIST. A HEALTH INSURING CORPORATION
MAY REQUIRE A PARTICIPATING OBSTETRICIAN OR GYNECOLOGIST TO COMPLY
WITH THE HEALTH INSURING CORPORATION'S COVERAGE PROTOCOLS AND
PROCEDURES, including utilization review, FOR OBSTETRIC AND GYNECOLOGICAL
SERVICES. A HEALTH INSURING CORPORATION policy, contract, or agreement MAY NOT IMPOSE
ADDITIONAL COPAYMENTS
FOR DIRECTLY ACCESSED OBSTETRIC AND GYNECOLOGICAL SERVICES, UNLESS
the policy, contract, or agreement imposes additional copayments for direct
access to any participating provider other than a primary care provider. Sec. 3901.80. As used in sections 3901.80 to 3901.83 of the Revised Code, "clinical
peer" and "physician" have the same meanings as in section 1751.77 of the Revised Code. (A) THE SUPERINTENDENT of insurance SHALL
ACCREDIT INDEPENDENT review organizations for the purposes of external reviews
conducted under sections
1751.84, 1751.85, 3923.67, 3923.68, 3923.76, and 3923.77 of the Revised Code. The
superintendent may, in accordance with Chapter 119. of the Revised Code and in
consultation with the director of health, adopt rules governing the
accreditation of independent review organizations. In DEVELOPING THE rules,
THE SUPERINTENDENT may TAKE INTO
CONSIDERATION THE STANDARDS ESTABLISHED BY NATIONAL ORGANIZATIONS
THAT ACCREDIT ORGANIZATIONS providing EXPERT REVIEWS AND
RELATED SERVICES. THE SUPERINTENDENT, after reviewing the accreditation
process used by a national organization to accredit an independent
review organization, may determine that accreditation by the national
organization constitutes accreditation by
the superintendent. The superintendent shall not accredit any independent
review organization that is operated by a national, state, or local trade
association of health benefit plans or health care providers. (B) Each INDEPENDENT review organization SHALL USE THE SERVICES
OF clinical peers outside the staff of the independent review organization to
conduct external reviews. None of the following shall choose, or control the
choice of, the clinical peers: (1) A health insuring corporation; (2) An enrollee; (3) An insurer; (4) An insured; (5) A public employee benefit plan; (6) A plan member. (C) The superintendent shall maintain a randomly organized roster
of independent review organizations accredited under this section for purposes
of assigning independent review organizations to
conduct external reviews. The superintendent may, in accordance with
Chapter 119. of the Revised Code, adopt rules governing the assignment of
independent review organizations. On receipt of a request by a health insuring corporation, insurer, or
public employee benefit plan, the superintendent shall randomly assign two
independent review organizations that are accredited under
division (A) of this section. After receipt of the names of the two
independent review
organizations, the health insuring corporation, insurer, or public employee
benefit plan shall select one of the assigned independent review organizations
to conduct the external review. No health insuring corporation, insurer, or public employee benefit plan
shall engage in a pattern of excluding a particular independent review
organization based on previous findings on behalf of enrollees, insureds, or
plan members. If the superintendent makes such a finding, it is an unfair
trade practice. Sec. 3901.81. An INDEPENDENT review organization selected under section
3901.80 of the Revised Code to conduct an external review
under section 1751.84, 3923.67, or 3923.76 of the Revised Code SHALL utilize the services of
CLINICAL PEERS WHO HAVE
EXPERTISE IN THE TREATMENT OF THE MEDICAL
CONDITION of the enrollee, insured, or plan member AND
CLINICAL EXPERIENCE in the past three years WITH THE SERVICE requested or
RECOMMENDED BY THE ENROLLEE, insured, or plan member
OR THE PROVIDER of the enrollee, insured, or plan member. The review shall be
conducted by a single
clinical peer, unless the health insuring corporation, insurer, or public
employee benefit plan
determines that more than one clinical peer is needed.
THE CLINICAL PEER MUST HOLD A LICENSE
THAT IS NOT RESTRICTED IN ANY MANNER BY THE STATE IN WHICH THE
CLINICAL PEER IS LICENSED. The clinical peer shall not have
been disciplined
or sanctioned by a hospital or government entity based on the quality of care
provided by the clinical peer. In the CASE OF A PHYSICIAN, THE
CLINICAL PEER MUST BE CERTIFIED BY A NATIONALLY RECOGNIZED MEDICAL
SPECIALTY BOARD IN THE AREA THAT IS THE SUBJECT OF THE REVIEW. Sec. 3901.82. (A) Each INDEPENDENT review organization that
conducts
EXTERNAL REVIEWS
UNDER SECTION 1751.84,
1751.85, 3923.67, 3923.68, 3923.76, or 3923.77 OF THE REVISED
CODE SHALL ANNUALLY REPORT THE
FOLLOWING
INFORMATION TO THE SUPERINTENDENT OF INSURANCE in a format prescribed by the
superintendent: (1) THE NUMBER OF reviews conducted; (2) THE NUMBER OF reviews DECIDED IN FAVOR OF ENROLLEES, insureds, and
plan members AND THE
NUMBER DECIDED IN FAVOR OF HEALTH INSURING CORPORATIONs, insurers, and public
employee benefit plans; (3) THE AVERAGE TIME REQUIRED TO conduct a review; (4) THE NUMBER AND PERCENTAGE OF reviews IN WHICH A DECISION WAS
NOT REACHED IN THE TIME REQUIRED UNDER DIVISION (D) OF SECTION
1751.84, DIVISION (C) OF SECTION 1751.85, division (D) of
section 3923.67, division (C) of section 3923.68, division
(D) of section 3923.76, or division (C) of section 3923.77
OF THE REVISED
CODE; (5) A summary of the diagnoses, drugs, devices, services, procedures, and
therapies that have been the subject of external review; (6) The costs associated with external reviews, including the rates
charged
by the independent review organization to conduct the reviews; (7) The medical specialty or type of provider used to conduct each
external review, as related to the specific medical condition of the enrollee,
insured, or plan member; (8) ANY ADDITIONAL INFORMATION REQUIRED BY THE SUPERINTENDENT BY
RULE ADOPTED PURSUANT TO DIVISION (C) OF THIS SECTION. (B) The superintendent of insurance shall comply with applicable
state and federal laws related to the confidentiality of medical records. (C) THE SUPERINTENDENT MAY, IN ACCORDANCE WITH CHAPTER
119.
OF THE
REVISED CODE, ADOPT RULES REQUIRING INDEPENDENT review
organizations TO
PROVIDE ADDITIONAL INFORMATION ON THE consideration AND DISPOSITION OF
EXTERNAL
reviews
BROUGHT UNDER SECTION 1751.84, 1751.85, 3923.67, 3923.68, 3923.76, or 3923.77
OF THE REVISED CODE. (D) THE SUPERINTENDENT SHALL COMPILE AND ANNUALLY PUBLISH THE
INFORMATION COLLECTED UNDER
THIS
SECTION AND REPORT THE INFORMATION TO THE GOVERNOR, THE SPEAKER and minority
leader OF THE HOUSE
OF
REPRESENTATIVES, THE PRESIDENT and minority leader OF THE SENATE, AND THE
CHAIRS and ranking minority members OF THE HOUSE AND
SENATE
COMMITTEES WITH JURISDICTION OVER HEALTH AND INSURANCE ISSUES. Sec. 3901.83. When a record containing information pertaining to
the medical history, diagnosis, prognosis, or medical condition of an enrollee
of a health insuring
corporation, insured of an insurer, or plan member of a public employee
benefit plan is provided to the superintendent of insurance for any
reason under sections 1751.77 to 1751.88, 3923.66 to 3923.70, or 3923.75 to
3923.79 of
the Revised
Code,
regardless of the source, The superintendent shall maintain the
confidentiality of the record. The record in the superintendent's
possession is not a public record under section 149.43 of the
Revised Code, except to the
extent that information from the record is used in preparing reports
under section 3901.82 of the Revised Code. Sec. 3901.84. An independent review organization and any
medical expert or
clinical peer the organization uses in conducting an external review under
section 1751.84, 1751.85, 3923.67, 3923.68, 3923.76, or 3923.77
of the Revised Code is not liable in damages in a civil
action for
injury, death, or loss to person or property and is not subject to
professional disciplinary action for making, in good faith, any finding,
conclusion,
or determination required to complete the external review. This section does not grant
immunity from
civil liability or professional disciplinary action to an independent review
organization, medical expert, or clinical peer for an action that is outside
the scope of
authority granted under section 1751.84, 1751.85, 3923.67, 3923.68, 3923.76,
or 3923.77 of the Revised
Code. Sec. 3923.65. (A) AS USED IN THIS SECTION: (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 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. (B) EVERY INDIVIDUAL OR GROUP POLICY OF SICKNESS AND ACCIDENT
INSURANCE THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL EXPENSE COVERAGE
SHALL COVER EMERGENCY SERVICES WITHOUT REGARD TO THE DAY OR TIME THE
EMERGENCY SERVICES ARE RENDERED OR TO WHETHER THE POLICYHOLDER,
THE HOSPITAL'S EMERGENCY DEPARTMENT WHERE THE SERVICES ARE
RENDERED, OR AN EMERGENCY PHYSICIAN TREATING THE POLICYHOLDER,
OBTAINED PRIOR AUTHORIZATION FOR THE EMERGENCY SERVICES. (C) EVERY INDIVIDUAL POLICY OR CERTIFICATE FURNISHED BY AN
INSURER
IN CONNECTION WITH ANY SICKNESS AND ACCIDENT INSURANCE POLICY SHALL
PROVIDE INFORMATION REGARDING THE FOLLOWING: (1) THE SCOPE OF COVERAGE FOR EMERGENCY 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 COPAYMENTS FOR EMERGENCY SERVICES. (D) THIS SECTION DOES NOT APPLY TO ANY INDIVIDUAL OR GROUP POLICY
OF SICKNESS AND ACCIDENT INSURANCE COVERING ONLY ACCIDENT, CREDIT,
DENTAL, DISABILITY INCOME, LONG-TERM CARE, HOSPITAL INDEMNITY, MEDICARE
SUPPLEMENT, MEDICARE, TRICARE, SPECIFIED DISEASE, OR VISION CARE;
COVERAGE UNDER A ONE-TIME LIMITED DURATION POLICY OF NO LONGER THAN SIX
MONTHS; COVERAGE ISSUED AS A SUPPLEMENT TO LIABILITY INSURANCE;
INSURANCE ARISING OUT OF WORKERS' COMPENSATION OR SIMILAR LAW;
AUTOMOBILE MEDICAL PAYMENT INSURANCE; OR INSURANCE UNDER WHICH
BENEFITS ARE PAYABLE WITH OR WITHOUT REGARD TO FAULT AND WHICH IS
STATUTORILY REQUIRED TO BE CONTAINED IN ANY LIABILITY INSURANCE
POLICY OR EQUIVALENT SELF-INSURANCE. Sec. 3923.66. (A) AS USED IN SECTIONS 3923.66 TO 3923.70 OF THE
REVISED CODE: (1) "CLINICAL PEER" AND "PHYSICIAN" HAVE THE SAME MEANINGS AS IN SECTION
1751.77 OF THE REVISED CODE. (2) "Authorized person" means a parent, guardian, or other person
authorized to act on behalf of an insured with respect to health care
decisions. (B) Sections 3923.66 to 3923.70 of the Revised
Code do not
apply to
any individual or group policy of sickness and accident insurance covering
only accident, credit, dental, disability income, long-term care, hospital
indemnity,
medicare supplement, medicare, tricare, specified disease, or
vision care; coverage issued as a supplement to liability
insurance; insurance arising out of workers' compensation or
similar law; automobile medical payment insurance; or insurance
under which benefits are payable with or without regard to fault
and which is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance. (C) The superintendent of insurance shall establish and maintain
a
system for receiving and reviewing requests for review from insureds who
have been denied COVERAGE OF a health care service on the grounds that
the service is not a service covered under the terms of the
insured's policy or certificate. On receipt of a written request from an insured OR AUTHORIZED
PERSON, the superintendent shall consider whether the health care
service is a service covered under the terms of the insured's
policy or certificate, except that the superintendent shall not
conduct a review under this section unless the insured has
exhausted the insurer's internal review process. The insurer and
the insured OR AUTHORIZED PERSON shall provide the superintendent
with any information REQUIRED BY THE SUPERINTENDENT THAT IS IN
THEIR POSSESSION AND IS GERMANE TO THE REVIEW. Unless THE SUPERINTENDENT is not able to do so because making the
determination requires resolution of a medical issue, the superintendent
shall determine whether the health care service at issue is a service
covered under the terms of the insured's policy or certificate. The
superintendent shall notify the insured and the insurer of its
determination or that it is not able to make a determination because the
determination requires the resolution of a medical issue. If the superintendent notifies the insurer that making the
determination requires the resolution of a medical issue, the insurer
shall afford the insured an opportunity for external review under
section 3923.67 or 3923.68 of the Revised Code. If the
superintendent notifies the insurer that the health care service is not a
covered service, the insurer is not required to cover the service or afford
the
insured an external review. Sec. 3923.67. (A) Except as provided in divisions
(B) and (C) of
this section, an insurer shall afford an insured an OPPORTUNITY for an
external review of a coverage denial when requested by the insured or
authorized person, if both of the following are the case: (1) The insurer has denied, reduced, or terminated coverage for
what would be a covered health care service except that the insurer has
determined that the health care service is not medically necessary. (2) except in the case of EXPEDITED review, The proposed service,
plus any ancillary services and follow-up care, will cost the insured
more than five hundred dollars if the proposed service is not covered by
the insurer. external review shall be conducted in accordance with this
section, except that if an insured with a terminal condition meets all
of the criteria of division (A) of section 3923.68 of the
Revised
Code, an external review shall be conducted under
that section. (B) An insured need not be afforded a review under this section
in any of the following circumstances: (1) the superintendent of insurance has determined under section
3923.66 of the Revised Code that the health care service is not a
service covered under the terms of the insured's policy or
certificate. (2) the insured has failed to exhaust the insurer's internal
review process. (3) the insured has previously afforded an external review for
the same denial of coverage, and no new clinical information has been
submitted to the insurer. (C)(1) An insurer may deny a request for an external review if it
is requested later than sixty days after receipt by the insured of NOTICE FROM
the superintendent of insurance under section
3923.66 of the Revised Code that making a determination requires the resolution of a medical
issue. An external review may be requested
by the insured, an authorized person, the insured's provider, or a
health care facility rendering health care service to the insured.
The insured may request a review without the approval of the
provider or the health care facility rendering the health care
service. The provider or health care facility may not request a
review without the prior consent of the insured. (2) An external review must be requested in writing, except that
if the insured has a condition that requires EXPEDITED review, the
review may be requested orally or by electronic means. When an oral
or electronic request for review is made, written confirmation of
the request must be submitted to the insurer not later than five
days after the request is made. Except in the case of an expedited review, a request for an
external review must be accompanied by written certification from the
insured's provider or the health care facility rendering the health care
service to the insured that the proposed service, plus any
ancillary services and follow-up care, will cost the insured more
than five hundred dollars if the proposed service is not covered
by the insurer. (3) For an expedited review, the insured's provider must certify
that the insured's condition could, in the absence of immediate medical
attention, result in any of the following: (a) Placing the health of the insured or, with respect to a
pregnant woman, the health of the insured or the unborn child, in serious
jeopardy; (b) Serious impairment to bodily functions; (c) Serious dysfunction of any bodily organ or part. (d) The procedures used in conducting an external review shall
include all of the following: (1) The review shall be conducted by an independent review
organization assigned by the superintendent of insurance under
section 3901.80 of the Revised Code. (2) eXCEPT AS PROVIDED IN dIVISIONs (d)(3) and (4) of this
section, neither the clinical peer nor any health care facility with which the
clinical peer is affiliated shall have any
professional, familial, or financial affiliation with any of the
following: (a) The insurer or any officer, director, or managerial
employee
of the insurer; (b) The insured, the insured's provider, or the practice
group of
the insured's provider; (c) The health care facility at which the health care service
requested by the insured would be provided; (d) the development or manufacture of the principal drug, device,
procedure, or therapy proposed for the insured. (3) Division (d)(2) of this section does not prohibit a clinical
peer from conducting a review under any of the following
circumstances: (a) The clinical peer is affiliated with an academic medical
center that provides health care services to insureds of the
insurer. (b) the clinical peer has staff privileges at a health care
facility that provides health care services to insureds of the
insurer. (c) The clinical peer has a contractual relationship with the
insurer but was not involved with the insurer's coverage decision. (4) Division (d)(2) of this section does not prohibit the insurer
from paying the independent review organization for the conduct OF the
review. (5) An insured shall not be required to pay for any part of the
cost of the review. The cost of the review shall be borne by the
insurer. (6)(a) The insurer shall provide to the independent
review organization conducting the review a copy of those records in its
possession that are
RELEVANT to the insured's medical
condition and the review. Records shall be used solely for
the purpose of this division. At the request of the independent
review organization, the insurer, insured, provider, or health
care facility rendering health care services to the insured shall
provide any additional information the independent review
organization requests to complete the review. A request for additional
information may be made in writing, orally, or by electronic means. the
independent review organization shall submit the request to the insured
and insurer. If a request is submitted orally or by
electronic means to an insured or insurer,
not later than five days after the request is submitted, the
independent review organization shall provide written confirmation
of the request. If the review was initiated by a provider or
health care facility, a copy of the request shall be submitted to
the provider or health care facility. (b) An independent review organization is not required to
make a
decision if it has not received any requested information that it
considers necessary to complete a review. An independent review
organization that does not make a decision for this reason shall notify
the insured and the insurer that a decision
is not being made. The notice may be made in writing, orally, or
by electronic means. An Oral or electronic notice shall be
confirmed in writing not later than five days after the oral or
electronic notice is made. If the review was initiated by a
provider or health care facility, a copy of the notice shall be
submitted to the provider or health care facility. (7) the insurer may
elect to cover the service requested and terminate the review.
The insurer shall notify the insured and all other parties
involved with the decision by mail, or with the consent or
approval of the insured, by electronic means. (8) In making its decision, an independent review organization
conducting the review shall take into account all of the
following: (a) Information submitted by the insurer, the insured, the
insured's provider, and the health care facility rendering the health
care service, including the following: (i) The insured's medical records; (ii) The standards, criteria, and clinical rationale used by the
insurer to make its DECISION. (b) Findings, studies, research, and other relevant documents of
government agencies and nationally recognized organizations, including the national institutes of health or any
board recognized by the national institutes of health, the
national cancer institute, the national academy of sciences, the
United States food and drug
ADMINISTRATION, the health care financing administration of the
United States department of
health and human services, and the agency for health care policy and
RESEARCH; (c) Relevant findings in peer-reviewed medical or scientific
literature, published opinions of nationally recognized medical experts, and clinical guidelines adopted by
relevant national medical societies. (9)(a) In the case of an expedited review, the independent review
organization shall issue a written decision not later than seven
days after the filing of the request for review. In all other
cases, the independent review organization shall issue a written
decision not later than thirty days after the filing of the
request. The independent review organization shall send a copy of
its decision to the insurer and the insured. If the insured's
provider or the health care facility rendering health care
services to the insured requested the review, the independent
review organization shall also send a copy of its decision to the
insured's provider or the health care facility. (b) The independent review organization's decision shall include
a description of the insured's condition and the principal reasons for the decision and an
explanation of the clinical rationale for the decision.(e) The independent review organization shall base its decision
on the information submitted under division (d)(8) of this
section. In making its decision, the independent review organization shall consider safety,
efficacy, appropriateness, and cost-effectiveness.(f) The insurer shall provide any coverage determined by the
independent review organization's decision to be medically necessary, subject to the other terms,
limitations, and conditions of the insured's policy or
certificate.Sec. 3923.68. (A) Each insurer shall establish a
reasonable
external, independent review process to examine the insurer's coverage
decisions for insureds who meet all of the
following criteria:(1) The insured has a terminal condition that, according to the
current diagnosis of the insured's physician, has a high probability of
causing death within two years. (2) the insured requests a review not later than sixty days after
receipt by the insured of notice from the superintendent of insurance
under section 3923.66 of the Revised Code that making a determination requires resolution of
a medical issue. (3) The insured's physician certifies that the insured has the
condition described in division (A)(1) of this section and any of
the following situations are applicable: (a) Standard therapies have not been effective in
improving the
condition of the insured. (b) Standard therapies are not medically appropriate for
the
insured. (c) There is no standard therapy covered by the insurer
that is
more beneficial than therapy described in division (A)(4) of this
section. (4) The insured's physician has recommended a drug, device,
procedure, or other therapy that the physician certifies, in writing, is
likely to be more beneficial to the insured, in the physician's opinion,
than standard therapies, or the insured 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. (5) The insured has been denied coverage by the insurer for a
drug, device, procedure, or other therapy recommended or requested
pursuant to division (A)(4) of this section, and has exhausted the
insurer's
internal review process. (6) The drug, device, procedure, or other therapy, for which
coverage has been denied, would be a covered health care service except
for the insurer's determination that the drug, device, procedure,
or other therapy is experimental or investigational. (B) a review shall be requested in writing, except that if the
insured's physician determines that a therapy would be significantly less
effective if not promptly
initiated, the review may be requested orally or by electronic
means. When an oral or electronic request for review is made,
written confirmation of the request shall be submitted to the
insurer not later than five days after the oral or written request is
submitted. (C) The external, independent review process established by an
insurer shall meet all of the following criteria: (1) Except as provided in division (e) of this section, the
process shall afford all insureds who meet the criteria set forth in
division (A) of this section the opportunity to have the
insurer's decision to deny coverage of the recommended or requested therapy
reviewed under
the process. Each eligible insured shall be notified of that opportunity
within thirty
business days after the insurer denies coverage. (2) The review shall be conducted by an independent review
organization assigned by the superintendent of insurance under
section 3901.80 of the Revised Code. The
independent review organization shall select a panel to conduct
the review, which panel shall be composed of at least three
physicians or other providers who, through clinical experience in
the past three years, are experts in the treatment of the
insured's medical condition and knowledgeable about the
recommended or requested therapy. In either of the following circumstances, an exception may be made
to the requirement that the review be conducted by an expert panel
composed of a minimum of three physicians or other providers: (a) A review may be conducted by an expert panel composed
of only
two physicians or other providers if an insured has consented in writing to a
review by the
smaller panel. (b) A review may be conducted by a single expert physician
or
other provider if only the expert physician or other provider is
available for the review. (3) Neither the insurer nor the insured shall choose, or control
the choice of, the physician or other provider experts. (4) the selected experts, any health care facility with which an
expert is affiliated, and the independent review organization arranging
for the experts' review shall not have any professional, familial, or
financial affiliation with any of the following: (a) The insurer or any officer, director, or managerial
employee
of the insurer; (b) the insured, the insured's physician, or the practice
group
of the insured's physician; (c) The health care facility at which the recommended or
requested
therapy would be provided; (d) the development or manufacture of the principal drug,
device,
procedure, or therapy involved in the recommended or requested therapy. However, experts
affiliated with academic medical centers who provide health care services to
insureds of the
insurer may serve as experts on the review panel. Further, experts
with staff PRIVILEGES at a health care facility that provides
health care services to insureds of the insurer, as well as
experts who have a contractual relationship with the insurer, but
who were not INVOLVED with the insurer's denial of coverage for
the therapy under review, may serve as experts on the review
panel. These nonaffiliation provisions do not preclude an insurer
from paying for the experts' review, as specified in division
(C)(5) of this section. (5) Insureds shall not be required to pay for any part of the
cost of the review. The cost of the review shall be borne by the
insurer. (6) The insurer shall provide to the independent review
organization arranging for the experts' review a copy of those records
in the insurer's possession that are relevant to the insured's medical
condition and the review. The records shall be disclosed solely to the
expert reviewers and shall be used solely for the purpose of this
section. At the request of the expert reviewers, the insurer or
the physician requesting the therapy shall provide any additional
information that the expert reviewers request to complete the
review. An expert reviewer is not required to render an opinion
if the reviewer has not received any requested information that
the reviewer considers necessary to complete the review. (7)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT review
organization SHALL ISSUE A WRITTEN DECISION NOT LATER THAN SEVEN DAYS AFTER
the FILING of
THE
REQUEST FOR REVIEW.
IN ALL OTHER CASES, THE INDEPENDENT review organization SHALL ISSUE A WRITTEN
DECISION NOT
LATER THAN THIRTY
DAYS AFTER THE FILING OF THE REQUEST. THE INDEPENDENT review organization
SHALL SEND A COPY OF ITS DECISION TO THE insurer and the
insured. IF THE insured's PROVIDER OR THE
HEALTH CARE FACILITY RENDERING HEALTH CARE SERVICES TO THE
insured REQUESTED THE review, THE INDEPENDENT review organization SHALL also
SEND A
COPY OF ITS DECISION TO THE insured's PROVIDER OR THE HEALTH CARE
FACILITY. (b) In conducting the review, the experts on the panel shall take
into account all of the following: (i) Information submitted by the insurer,
the insured, and the insured's physician, including the insured's medical
records and the standards, criteria, and
clinical rationale used by the insurer to
reach its coverage decision; (ii) Findings, studies, research, and other relevant documents of
government agencies and nationally recognized organizations; (iii) Relevant findings in peer-reviewed medical or scientific
literature and published opinions of nationally recognized medical
experts; (iv) Clinical guidelines adopted by relevant national medical
societies; (v) SAFETY, EFFICACY, APPROPRIATENESS, AND COST EFFECTIVENESS. (8) Each expert on the panel shall provide the independent review
organization with a professional opinion as to whether there is
sufficient evidence to demonstrate that the recommended or requested
therapy is likely to be more beneficial to the insured than
standard therapies. (9) Each expert's opinion shall be presented in written form and
shall include the following information: (a) A description of the insured's condition; (b) A description of the indicators relevant to
determining
whether there is sufficient evidence to demonstrate that the recommended or
requested
therapy is more likely than not to be more beneficial to the insured 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 insured's suitability to receive
the
recommended or requested therapy according to a treatment protocol in a
clinical trial, if
applicable. (10) The independent review organization shall provide the
insurer with the opinions of the experts. The insurer shall make the
experts' opinions available to the insured and the insured's physician,
upon request. (11) The opinion of the majority of the experts on the panel,
rendered pursuant to division (C)(8) of this section, is binding
on the insurer with respect to that insured. If the opinions of the experts
on the panel are
evenly divided as to whether the therapy should be covered, the insurer'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 insurer may, in
its discretion, cover the therapy. However, any coverage provided
pursuant to division (C)(11) of this section is subject to the
terms, limitations, and conditions of the insured's policy or
certificate with the insurer. (12) The insurer shall have written policies describing the
external, independent review process. (D) If an insurer's initial denial of coverage for a therapy
recommended or requested pursuant to division (a)(3) of this
section is based upon an external, independent review of that therapy meeting
the requirements of
division (C) of this section, this section shall not be a basis
for requiring a second external, independent review of the recommended or
requested therapy. (E) At any time during the external, independent review process,
the insurer may elect to cover the recommended or requested health care
service and terminate the review.
The insurer shall notify the insured and all other parties
involved by mail or, with consent or approval of the insured, by
electronic means. (F) The insurer shall annually file a certificate with the
superintendent of insurance certifying its compliance with the
requirements of this section. Sec. 3923.681. (A) If, after notice and hearing, the
superintendent of
insurance finds that an insurer has failed to comply with section 3923.66 or
3923.67 of the Revised Code, the superintendent may suspend
or revoke the insurer's license to transact business within the state. (B)(1) In lieu of
the suspension or revocation of a license under division (A) of this
section, the superintendent of
insurance, pursuant to an adjudication hearing initiated and
conducted in accordance with Chapter 119. of the Revised
Code, or by consent of the
insurer without an adjudication hearing, may
levy an administrative penalty. The administrative penalty shall be in an
amount determined by the
superintendent, but the administrative penalty shall not exceed one hundred
thousand dollars per violation. Additionally, the
superintendent may
require the insurer to
correct any deficiency that may be the basis for the suspension
or revocation of the insurer's license. All penalties collected shall be paid
into the
state treasury to the credit of the department of insurance
operating fund. (2) If the
superintendent for any reason has
cause to believe that any violation of section 3923.66 or 3923.67 of the Revised Code has
occurred
or is threatened, the superintendent may give
notice to the insurer and to the
representatives or other persons who appear to be involved in
the suspected violation to arrange a conference with the
suspected violators or their authorized representatives for the
purpose of attempting to ascertain the facts relating to the
suspected violation, and, if it appears that any violation has
occurred or is threatened, to arrive at an adequate and
effective means of correcting or preventing the violation. Proceedings shall not be covered by
any formal procedural requirements, and may be conducted in the
manner the superintendent may consider
appropriate under the circumstances. (3)(a) The superintendent may issue an order directing an insurer
or a representative of the insurer to cease and desist from engaging in any
act or
practice in violation of section 3923.67 or 3923.68 of the Revised Code. Within thirty days
after
service of the order to cease and desist, the respondent may
request a hearing on the question of whether acts or practices
in violation of those sections have occurred. Such hearings shall
be conducted in accordance with Chapter 119. of the Revised
Code and judicial review shall
be available as provided by that chapter. (b) If the superintendent has reasonable cause to believe
that an order has been violated
in whole or in part, the superintendent may request the attorney
general to commence and prosecute any appropriate action or
proceeding in the name of the state against the violators in the
court of common pleas of
Franklin county. The court in
any such action or proceeding may levy civil penalties, not to
exceed one hundred thousand dollars per violation, in addition
to any other appropriate relief, including requiring a violator
to pay the expenses reasonably incurred by the superintendent in
enforcing the order. The penalties and fees collected shall be paid into the
state treasury to the
credit of the department of insurance operating fund. Sec. 3923.69. Nothing in sections 3923.66 to 3923.68 of the
Revised Code shall be construed
to create a cause of action against any of the following: (A) An employer that
provides health care
benefits to employees through an insurer; (B) A clinical peer, medical expert, or independent
review organization that
participates in an external review under section 3923.67 or
3923.68 of the Revised Code; (C) An insurer that provides
coverage
for benefits pursuant to section 3923.67 or 3923.68 of the Revised
Code. Sec. 3923.70. Consistent with the rules of
evidence, a written
decision or opinion prepared by an independent review organization under
section 3923.67 or 3923.68 of the Revised Code shall be
admissible in any civil action related to the coverage decision that was the
subject of the decision or opinion. The
independent review organization's decision or opinion shall be
presumed to be a scientifically valid and accurate description of
the state of medical knowledge at the time it was written. Consistent with the rules of evidence, any party to a
civil action
related to an insurer's decision involving an investigational or experimental drug, device, or treatment may introduce into evidence any
applicable medicare reimbursement standards established under
Title XVIII of the "Social
Security Act," 49 Stat. 620
(1935), 42 U.S.C.A. 301, as amended. Sec. 3923.75. (A) AS USED IN SECTIONS 3923.75 TO 3923.79 OF THE
REVISED CODE: (1) "CLINICAL PEER" AND "PHYSICIAN" HAVE THE SAME MEANINGS AS IN SECTION
1751.77 OF THE REVISED CODE. (2) "Authorized person" means a parent, guardian, or other person
authorized to act on behalf of a plan member with respect to health care
decisions. (B) Sections 3923.75 to 3923.79 of the Revised
Code do not
apply to
any public employee benefit plan covering only accident, credit, dental,
disability income, long-term care, hospital indemnity,
medicare supplement, medicare, tricare, specified disease, or
vision care; coverage issued as a supplement to liability
insurance; insurance arising out of workers' compensation or
similar law; automobile medical payment insurance; or insurance
under which benefits are payable with or without regard to fault
and which is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance. (C) The superintendent of insurance shall establish and maintain
a
system for receiving and reviewing requests for review from plan members who
have been denied COVERAGE OF a health care service on the grounds that
the service is not a service covered under the terms of the
public employee benefit plan. On receipt of a written request from a plan member OR AUTHORIZED
PERSON, the superintendent shall consider whether the health care
service is a service covered under the terms of the plan,
except that the superintendent shall not
conduct a review under this section unless the plan member has
exhausted the plan's internal review process. The plan and
the plan member OR AUTHORIZED PERSON shall provide the superintendent
with any information REQUIRED BY THE SUPERINTENDENT THAT IS IN
THEIR POSSESSION AND IS GERMANE TO THE REVIEW. Unless THE SUPERINTENDENT is not able to do so because making the
determination requires resolution of a medical issue, the superintendent
shall determine whether the health care service at issue is a service
covered under the terms of the plan. The
superintendent shall notify the plan member and the plan of its
determination or that it is not able to make a determination because the
determination requires the resolution of a medical issue. If the superintendent notifies the plan that making the
determination requires the resolution of a medical issue, the plan
shall afford the plan member an opportunity for external review under
section 3923.76 or 3923.77 of the Revised Code. If the
superintendent notifies the plan that the health care service is not a covered
service, the plan is not required to cover the service or afford the
plan member an external review. Sec. 3923.76. (A) Except as provided in divisions
(B) and (C) of
this section, a public employee benefit plan shall afford a plan member an
OPPORTUNITY for an
external review of a coverage denial when requested by the plan member or
authorized person, if both of the following are the case: (1) The plan has denied, reduced, or terminated coverage for
what would be a covered health care service except that the plan has
determined that the health care service is not medically necessary. (2) except in the case of EXPEDITED review, The proposed service,
plus any ancillary services and follow-up care, will cost the plan member
more than five hundred dollars if the proposed service is not covered by
the plan. external review shall be conducted in accordance with this
section, except that if a plan member with a terminal condition meets all
of the criteria of division (A) of section 3923.77 of the
Revised
Code, an external review shall be conducted under
that section. (B) A plan member need not be afforded a review under this
section
in any of the following circumstances: (1) the superintendent of insurance has determined under section
3923.75 of the Revised Code that the health care service is not a
service covered under the terms of the plan. (2) the plan member has failed to exhaust the plan's internal
review process. (3) the plan member has previously been afforded an external review for
the same denial of coverage, and no new clinical information has been
submitted to the plan. (C)(1) A plan may deny a request for an external review if it
is requested later than sixty days after receipt by the plan member of NOTICE
FROM the superintendent of insurance under section
3923.75 of the Revised Code that making the determination requires the resolution of a
medical
issue. An external review may be requested
by the plan member, an authorized person, the plan member's provider, or a
health care facility rendering health care service to the plan member.
The plan member may request a review without the approval of the
provider or the health care facility rendering the health care
service. The provider or health care facility may not request a
review without the prior consent of the plan member. (2) An external review must be requested in writing, except that
if the plan member has a condition that requires EXPEDITED review, the
review may be requested orally or by electronic means. When an oral
or electronic request for review is made, written confirmation of
the request must be submitted to the plan not later than five
days after the request is made. Except in the case of an expedited review, a request for an
external review must be accompanied by written certification from the
plan member's provider or the health care facility rendering the health care
service to the plan member that the proposed service, plus any
ancillary services and follow-up care, will cost the plan member more
than five hundred dollars if the proposed service is not covered
by the plan. (3) For an expedited review, the plan member's provider must certify
that the plan member's condition could, in the absence of immediate medical
attention, result in any of the following: (a) Placing the health of the plan member or, with respect
to a
pregnant woman, the health of the plan member or the unborn child, in serious
jeopardy; (b) Serious impairment to bodily functions; (c) Serious dysfunction of any bodily organ or part. (d) The procedures used in conducting an external review shall
include all of the following: (1) The review shall be conducted by an independent review
organization assigned by the superintendent of insurance under
section 3901.80 of the Revised Code. (2) eXCEPT AS PROVIDED IN dIVISIONs (d)(3) and (4) of this
section, neither the clinical peer nor any health care facility with which the
clinical peer is affiliated shall have any
professional, familial, or financial affiliation with any of the
following: (a) The plan or any officer, director, or managerial
employee
of the plan; (b) The plan member, the plan member's provider, or the
practice group of
the plan member's provider; (c) The health care facility at which the health care
service
requested by the plan member would be provided; (d) the development or manufacture of the principal drug,
device,
procedure, or therapy proposed for the plan member. (3) Division (d)(2) of this section does not prohibit a clinical
peer from conducting a review under any of the following
circumstances: (a) The clinical peer is affiliated with an academic
medical
center that provides health care services to members of the
plan. (b) the clinical peer has staff privileges at a health
care
facility that provides health care services to members of the
plan. (c) The clinical peer has a contractual relationship with
the
plan but was not involved with the plan's coverage decision. (4) Division (d)(2) of this section does not prohibit the plan
from paying the independent review organization for the conduct OF the
review. (5) A plan member shall not be required to pay for any part of the
cost of the review. The cost of the review shall be borne by the
plan. (6)(a) The plan shall provide to the independent review
organization
conducting the review a copy of those records in its possession that are
RELEVANT to the plan member's medical
condition and the review. Records shall be used solely for
the purpose of this division. At the request of the independent
review organization, the plan, plan member, provider, or health
care facility rendering health care services to the plan member shall
provide any additional information the independent review
organization requests to complete the review. A request for additional
information may be made in writing, orally, or by electronic means. the
independent review organization shall submit the request to the plan member
and the plan. If a request is submitted orally or by
electronic means to a plan member or plan,
not later than five days after the request is submitted, the
independent review organization shall provide written confirmation
of the request. If the review was initiated by a provider or
health care facility, a copy of the request shall be submitted to
the provider or health care facility. (b) An independent review organization is not required to
make a
decision if it has not received any requested information that it
considers necessary to complete a review. An independent review
organization that does not make a decision for this reason shall notify
the plan member and the plan that a decision
is not being made. The notice may be made in writing, orally, or
by electronic means. An Oral or electronic notice shall be
confirmed in writing not later than five days after the oral or
electronic notice is made. If the review was initiated by a
provider or health care facility, a copy of the notice shall be
submitted to the provider or health care facility. (7) The plan may
elect to cover the service requested and terminate the review.
The plan shall notify the plan member and all other parties
involved with the decision by mail, or with the consent or
approval of the plan member, by electronic means. (8) In making its decision, an independent review organization
conducting the review shall take into account all of the
following: (a) Information submitted by the plan, the plan member,
the
plan member's provider, and the health care facility rendering the health
care service, including the following: (i) The plan member's medical records; (ii) The standards, criteria, and clinical rationale used
by the
plan to make its DECISION. (b) Findings, studies, research, and other relevant
documents of
government agencies and nationally recognized organizations, including the
national institutes of health or any
board recognized by the national institutes of health, the
national cancer institute, the national academy of sciences, the
United States food and drug
ADMINISTRATION, the health care financing administration of the
United States department of
health and human services, and the agency for health care policy and
RESEARCH; (c) Relevant findings in peer-reviewed medical or
scientific
literature, published opinions of nationally recognized medical experts, and
clinical guidelines adopted by
relevant national medical societies. (9)(a) In the case of an expedited review, the independent review
organization shall issue a written decision not later than seven
days after the filing of the request for review. In all other
cases, the independent review organization shall issue a written
decision not later than thirty days after the filing of the
request. The independent review organization shall send a copy of
its decision to the plan and the plan member. If the plan member's
provider or the health care facility rendering health care
services to the plan member requested the review, the independent
review organization shall also send a copy of its decision to the
plan member's provider or the health care facility. (b) The independent review organization's decision shall
include
a description of the plan member's condition and the principal reasons for the
decision and an
explanation of the clinical rationale for the decision. (e) The independent review organization shall base its decision
on the information submitted under division (d)(8) of this
section. In making its decision, the independent review organization shall
consider safety,
efficacy, appropriateness, and cost-effectiveness. (f) The plan shall provide any coverage determined by the
independent review organization's decision to be medically necessary, subject
to the other terms,
limitations, and conditions of the plan. Sec. 3923.77. (A) Each public employee benefit plan shall
establish a reasonable
external review process to examine the plan's coverage decisions for plan
members who meet all of the
following criteria: (1) The plan member has a terminal condition that, according to the
current diagnosis of the plan member's physician, has a high probability of
causing death within two years. (2) the plan member requests a review not later than sixty days after
receipt by the plan member of notice from the superintendent of insurance
under section 3923.75 of the Revised Code that making a determination requires resolution of
a medical issue. (3) The plan member's physician certifies that the plan member has the
condition described in division (A)(1) of this section and any of
the following situations are applicable: (a) Standard therapies have not been effective in
improving the
condition of the plan member. (b) Standard therapies are not medically appropriate for
the
plan member. (c) There is no standard therapy covered by the plan that
is
more beneficial than therapy described in division (A)(4) of this
section. (4) The plan member's physician has recommended a drug, device,
procedure, or other therapy that the physician certifies, in writing, is
likely to be more beneficial to the plan member, in the physician's opinion,
than standard therapies, or the plan member 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. (5) The plan member has been denied coverage by the plan for a
drug, device, procedure, or other therapy recommended or requested
pursuant to division (A)(4) of this section, and has exhausted all
internal appeals. (6) The drug, device, procedure, or other therapy, for which
coverage has been denied, would be a covered health care service except
for the plan's determination that the drug, device, procedure,
or other therapy is experimental or investigational. (B) A review shall be requested in writing, except that if the
plan member's physician determines that a therapy would be significantly less
effective if not promptly
initiated, the review may be requested orally or by electronic
means. When an oral or electronic request for review is made,
written confirmation of the request shall be submitted to the
plan not later than five days after the oral or written request is submitted.
For an expedited review, the plan member's provider must certify that the
requested or recommended therapy would be significantly less effective if not
promptly initiated. (C) The external review process established by a
plan shall meet all of the following criteria: (1) Except as provided in division (e) of this section, the
process shall afford all plan members who meet the criteria set forth in
division (A) of this section the opportunity to have the
plan's decision to deny coverage of the recommended or requested therapy
reviewed under
the process. Each eligible plan member shall be notified of that opportunity
within thirty
business days after the plan denies coverage. (2) The review shall be conducted by an independent review
organization assigned by the superintendent of insurance under
section 3901.80 of the Revised Code. The
independent review organization shall select a panel to conduct
the review, which panel shall be composed of at least three
physicians or other providers who, through clinical experience in
the past three years, are experts in the treatment of the
plan member's medical condition and knowledgeable about the
recommended or requested therapy. If the independent review
organization retained by the plan is an academic medical
center, the panel may include experts affiliated with or employed
by the academic medical center. In either of the following circumstances, an exception may be made
to the requirement that the review be conducted by an expert panel
composed of a minimum of three physicians or other providers: (a) A review may be conducted by an expert panel composed of only
two physicians or other providers if a plan member has consented in writing to
a review by the smaller panel. (b) A review may be conducted by a single expert physician
or other provider if only the expert physician or other provider is
available for the review. (3) Neither the plan nor the plan member shall choose, or control
the choice of, the physician or other provider experts. (4) The selected experts, any health care facility with which an
expert is affiliated, and the independent review organization arranging
for the experts' review shall not have any professional, familial, or
financial affiliation with any of the following: (a) The plan or any officer, director, or managerial employee of
the plan; (b) The plan member, the plan member's physician, or the practice
group of the plan member's physician; (c) The health care facility at which the recommended or
requested therapy would be provided; (d) The development or manufacture of the principal drug, device,
procedure, or therapy involved in the recommended or requested therapy.
However, experts
affiliated with academic medical centers who provide health care services to
members of the
plan may serve as experts on the review panel. Further, experts
with staff PRIVILEGES at a health care facility that provides
health care services to members of the plan, as well as
experts who have a contractual relationship with the plan, but
who were not INVOLVED with the plan's denial of coverage for
the therapy under review, may serve as experts on the review
panel. These nonaffiliation provisions do not preclude a plan
from paying for the experts' review, as specified in division
(C)(5) of this section. (5) Plan members shall not be required to pay for any part of the
cost of the review. The cost of the review shall be borne by the
plan. (6) The plan shall provide to the independent review
organization arranging for the experts' review a copy of those records
in the plan's possession that are relevant to the plan member's medical
condition and the review. The records shall be disclosed solely to the
expert reviewers and shall be used solely for the purpose of this
section. At the request of the expert reviewers, the plan or
the physician requesting the therapy shall provide any additional
information that the expert reviewers request to complete the
review. An expert reviewer is not required to render an opinion
if the reviewer has not received any requested information that
the reviewer considers necessary to complete the review. (7)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT review
organization SHALL ISSUE A WRITTEN DECISION NOT LATER THAN SEVEN DAYS AFTER
the FILING of THE REQUEST FOR REVIEW.
IN ALL OTHER CASES, THE INDEPENDENT review organization SHALL ISSUE A WRITTEN
DECISION NOT
LATER THAN THIRTY
DAYS AFTER THE FILING OF THE REQUEST. THE INDEPENDENT review organization
SHALL SEND A COPY OF ITS DECISION TO THE plan AND THE plan member. IF THE
plan member'S PROVIDER OR THE
HEALTH CARE FACILITY RENDERING HEALTH CARE SERVICES TO THE
plan member REQUESTED THE review, THE INDEPENDENT review organization SHALL
also
SEND A
COPY OF ITS DECISION TO THE plan member'S PROVIDER OR THE HEALTH CARE
FACILITY. (b) In conducting the review, the experts on the panel shall take
into account all of the following: (i) Information submitted by the plan,
the plan member, and the plan member's physician, including the plan member's
medical records and the standards, criteria, and
clinical rationale used by the plan to
reach its coverage decision; (ii) Findings, studies, research, and other relevant documents of
government agencies and nationally recognized organizations; (iii) Relevant findings in peer-reviewed medical or scientific
literature and published opinions of nationally recognized medical
experts; (iv) Clinical guidelines adopted by relevant national medical
societies; (v) SAFETY, EFFICACY, APPROPRIATENESS, AND COST EFFECTIVENESS. (8) Each expert on the panel shall provide the independent review
organization with a professional opinion as to whether there is
sufficient evidence to demonstrate that the recommended or requested
therapy is likely to be more beneficial to the plan member than
standard therapies. (9) Each expert's opinion shall be presented in written form and
shall include the following information: (a) a description of the plan member's condition; (b) A description of the indicators relevant to determining
whether there is sufficient evidence to demonstrate that the recommended or
requested therapy is more likely than not to be more beneficial to the plan
member 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 plan member's suitability to receive
the recommended or requested therapy according to a treatment protocol in a
clinical trial, if
applicable. (10) The independent review organization shall provide the
plan with the opinions of the experts. The plan shall make the
experts' opinions available to the plan member and the plan member's
physician,
upon request. (11) The opinion of the majority of the experts on the panel,
rendered pursuant to division (C)(8) of this section, is binding
on the plan with respect to that plan member. If the opinions of the experts
on the panel are
evenly divided as to whether the therapy should be covered, 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 (C)(11) of this section is subject to the
terms, limitations, and conditions of the plan. (12) The plan shall have written policies describing the
external review process. (D) If a plan's initial denial of coverage for a therapy
recommended or requested pursuant to division (a)(3) of this
section is based upon an external review of that therapy meeting the
requirements of
division (C) of this section, this section shall not be a basis
for requiring a second external review of the recommended or
requested therapy. (E) At any time during the external review process,
the plan may elect to cover the recommended or requested health care service
and terminate the review.
The plan shall notify the plan member and all other parties
involved by mail or, with consent or approval of the plan member, by
electronic means. (F) The plan shall annually file a certificate with the
superintendent of insurance certifying its compliance with the
requirements of this section. Sec. 3923.78. Nothing in sections 3923.75 to 3923.79 of the
Revised Code shall be construed
to create a cause of action against any of the following: (A) An employer that
provides health care
benefits to employees through an insurer; (B) A clinical peer, medical expert, or independent
review organization that
participates in an external review under section 3923.76 or
3923.77 of the Revised Code; (C) A plan that provides
coverage
for benefits pursuant to section 3923.76 or 3923.77 of the Revised
Code. Sec. 3923.79. Consistent with the Rules of
Evidence, a written
decision or opinion prepared by an independent review organization under
section 3923.76 or 3923.77 of the Revised Code shall be
admissible in any civil action related to the coverage decision that was the
subject of the decision or opinion. The
independent review organization's decision or opinion shall be
presumed to be a scientifically valid and accurate description of
the state of medical knowledge at the time it was written. Consistent with the Rules of Evidence, any party to a
civil action related to a plan's decision involving an investigational or
experimental drug, device, or treatment may introduce into evidence any
applicable medicare reimbursement standards established under
Title XVIII of the "Social
Security Act," 49 Stat. 620
(1935), 42 U.S.C.A. 301, as amended. Sec. 5747.01. Except as otherwise expressly provided or
clearly appearing from the context, any term used in this chapter
has the same meaning as when used in a comparable context in the
Internal Revenue Code, and all other statutes of the United
States relating to federal income taxes. As used in this chapter: (A) "Adjusted gross income" or "Ohio adjusted gross
income" means adjusted gross income as defined and used in the
Internal Revenue Code, adjusted as provided in divisions
(A)(1) to (17) of this section: (1) Add interest or dividends on obligations or securities
of any state or of any political subdivision or authority of any
state, other than this state and its subdivisions and authorities. (2) Add interest or dividends on obligations of any
authority, commission, instrumentality, territory, or possession
of the United States that are exempt from federal income taxes
but not from state income taxes. (3) Deduct interest or dividends on obligations of the
United States and its territories and possessions or of any
authority, commission, or instrumentality of the United States to
the extent included in federal adjusted gross income but exempt
from state income taxes under the laws of the United States. (4) Deduct disability and survivor's benefits to the
extent included in federal adjusted gross income. (5) Deduct benefits under Title II of the Social Security
Act and tier 1 railroad retirement benefits to the extent
included in federal adjusted gross income under section 86 of the
Internal Revenue Code. (6) Add, in the case of a taxpayer who is a beneficiary of
a trust that makes an accumulation distribution as defined in
section 665 of the Internal Revenue Code, the portion, if any, of
such distribution that does not exceed the undistributed net
income of the trust for the three taxable years preceding the
taxable year in which the distribution is made. "Undistributed
net income of a trust" means the taxable income of the trust
increased by (a)(i) the additions to adjusted gross income
required under division (A) of this section and (ii) the personal
exemptions allowed to the trust pursuant to section 642(b) of the
Internal Revenue Code, and decreased by (b)(i) the deductions to
adjusted gross income required under division (A) of this
section, (ii) the amount of federal income taxes attributable to
such income, and (iii) the amount of taxable income that has been
included in the adjusted gross income of a beneficiary by reason
of a prior accumulation distribution. Any undistributed net
income included in the adjusted gross income of a beneficiary
shall reduce the undistributed net income of the trust commencing
with the earliest years of the accumulation period. (7) Deduct the amount of wages and salaries, if any, not
otherwise allowable as a deduction but that would have been
allowable as a deduction in computing federal adjusted gross
income for the taxable year, had the targeted jobs credit allowed
and determined under sections 38, 51, and 52 of the Internal
Revenue Code not been in effect. (8) Deduct any interest or interest equivalent on public
obligations and purchase obligations to the extent included in
federal adjusted gross income. (9) Add any loss or deduct any gain resulting from the
sale, exchange, or other disposition of public obligations to the
extent included in federal adjusted gross income. (10) Regarding tuition credits purchased under Chapter 3334. of the Revised
Code: (a) Deduct the following: (i) For credits that as of the end of the taxable
year have not been refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised
Code, the amount of income related to the
credits, to the extent included in federal adjusted gross income; (ii) For credits that during the taxable year have
been refunded pursuant to the termination of a tuition payment contract under
section 3334.10 of the Revised Code, the excess of the total purchase price
of the tuition credits refunded over the amount of refund, to the extent the
amount of the excess was not deducted in determining federal adjusted
gross income;. (b) Add the following: (i) For credits that as of the end of the taxable
year have not been refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the amount of loss related
to the credits, to the extent the amount of the loss was deducted in
determining federal adjusted gross income; (ii) For credits that during the taxable year have
been refunded pursuant to the termination of a tuition payment contract under
section 3334.10 of the Revised
Code, the excess of the amount of refund over
the purchase price of each tuition credit refunded, to the extent not included
in federal adjusted gross income. (11)(a) Deduct, in the case of a self-employed individual as
defined in section 401(c)(1) of the Internal Revenue Code and to
the extent not otherwise allowable as a deduction or exclusion in
computing
federal or Ohio adjusted gross income for the taxable year,
the amount
the taxpayer paid during the taxable year for insurance that
constitutes medical care insurance and qualified long-term care
insurance for the taxpayer, the taxpayer's spouse, and
dependents. No
deduction for medical care insurance under division (A)(11) of this
section shall be allowed
either to any taxpayer who is eligible to participate in any subsidized
health plan maintained by any employer of the taxpayer or of the
taxpayer's spouse of the taxpayer. No
deduction under
division (A)(11) of
this section shall be allowed to the extent that the sum of such
deduction and any related deduction allowable in computing
federal adjusted gross income for the taxable year exceeds the
taxpayer's earned income, within the meaning of section 401(c) of
the Internal Revenue Code, derived by the taxpayer from the trade
or business with respect to which the plan providing
the medical
coverage is established.,
or to any taxpayer who is entitled to, or on application would be entitled
to, benefits under part A of Title XVIII of the
"Social Security Act," 49 Stat. 620
(1935), 42 U.S.C. 301, as amended. FOR THE PURPOSES OF DIVISION
(A)(11)(a) OF THIS SECTION,
"SUBSIDIZED HEALTH PLAN" MEANS A
HEALTH PLAN FOR WHICH THE EMPLOYER PAYS ANY PORTION OF THE plan's COST.
THE DEDUCTION ALLOWED UNDER DIVISION (A)(11)(a) OF
THIS
SECTION
SHALL BE the NET OF ANY related PREMIUM REFUNDS, related premium
REIMBURSEMENTS, OR related INSURANCE premium
DIVIDENDS
RECEIVED DURING THE TAXABLE
YEAR. (b) DEDUCT, TO THE EXTENT NOT OTHERWISE DEDUCTED OR EXCLUDED IN
COMPUTING FEDERAL OR OHIO ADJUSTED GROSS INCOME DURING THE TAXABLE
YEAR, THE AMOUNT THE TAXPAYER PAID DURING THE TAXABLE YEAR, NOT
COMPENSATED FOR BY ANY INSURANCE OR OTHERWISE, FOR MEDICAL CARE OF THE
TAXPAYER, THE TAXPAYER'S SPOUSE, AND DEPENDENTS, TO THE EXTENT THE
EXPENSES EXCEED SEVEN AND ONE-HALF PER CENT OF THE TAXPAYER'S
FEDERAL ADJUSTED GROSS INCOME. (c) FOR PURPOSES OF DIVISION (A)(11) OF THIS SECTION,
"MEDICAL
CARE" HAS THE MEANING GIVEN IN SECTION 213 OF THE INTERNAL
REVENUE CODE, SUBJECT TO THE SPECIAL RULES, LIMITATIONS, AND
EXCLUSIONS SET FORTH THEREIN, AND "QUALIFIED LONG-TERM CARE" HAS THE SAME
MEANING GIVEN IN SECTION 7702(B)(b) OF THE INTERNAL
REVENUE CODE. (12)(a) Deduct any amount included in federal adjusted gross
income solely because the amount represents a reimbursement or
refund of expenses that in a previous any year the taxpayer had
deducted as an itemized deduction pursuant to section 63 of the
Internal Revenue Code and applicable United States
department of the treasury regulations.
THE DEDUCTION OTHERWISE ALLOWED UNDER DIVISION (A)(12)(a) OF
THIS
SECTION SHALL BE REDUCED TO THE EXTENT THE REIMBURSEMENT IS
ATTRIBUTABLE TO AN AMOUNT THE TAXPAYER DEDUCTED UNDER THIS
SECTION IN ANY TAXABLE YEAR. (b) ADD ANY AMOUNT NOT OTHERWISE INCLUDED IN OHIO ADJUSTED
GROSS
INCOME FOR
ANY TAXABLE YEAR TO THE EXTENT THAT THE AMOUNT IS ATTRIBUTABLE TO THE RECOVERY
DURING THE TAXABLE YEAR
OF ANY AMOUNT DEDUCTED OR EXCLUDED IN COMPUTING FEDERAL OR OHIO
ADJUSTED GROSS INCOME IN ANY TAXABLE YEAR. (13) Deduct any portion of the deduction described in
section 1341(a)(2) of the Internal Revenue Code, for repaying
previously reported income received under a claim of right, that
meets both of the following requirements: (a) It is allowable for repayment of an item that was
included in the taxpayer's adjusted gross income for a prior
taxable year and did not qualify for a credit under division (A)
or (B) of section 5747.05 of the Revised Code for that year; (b) It does not otherwise reduce the taxpayer's adjusted
gross income for the current or any other taxable year. (14) Deduct an amount equal to the deposits made to, and
net investment earnings of, a medical savings account during the taxable year,
in accordance with section 3924.66 of the Revised Code. The deduction
allowed by division (A)(14) of this section does not apply to medical
savings account deposits and earnings otherwise deducted or excluded for the
current or any other taxable year from the taxpayer's federal adjusted gross
income. (15)(a) Add an amount equal to the funds withdrawn from a medical
savings account during the taxable year, and the net investment earnings on
those funds, when the funds withdrawn were used for any purpose other than to
reimburse an account holder for, or to pay, eligible medical expenses, in
accordance with section 3924.66 of the Revised Code; (b) Add the amounts distributed from a medical savings account
under division (A)(2) of section 3924.68 of the Revised Code during the
taxable year. (16) Add any amount claimed as a credit under section 5747.059 of the Revised
Code to the extent that such amount satisfies either of the following: (a) The amount was deducted or excluded from the computation of the
taxpayer's federal adjusted gross income as required to be reported for the
taxpayer's taxable year under the Internal Revenue Code; (b) The amount resulted in a reduction of the taxpayer's federal adjusted
gross income as required to be reported for any of the taxpayer's taxable
years under the Internal Revenue Code. (17) Deduct the amount contributed by the taxpayer to an
individual development account program established by a county department of
human services pursuant to sections 329.11 to 329.14 of the Revised Code for
the purpose of matching funds deposited by program participants. On request of
the tax commissioner, the taxpayer shall provide any information that, in the
tax commissioner's opinion, is necessary to establish the amount deducted under
division (A)(17) of this section. (B) "Business income" means income arising from
transactions, activities, and sources in the regular course of a
trade or business and includes income from tangible and
intangible property if the acquisition, rental, management, and
disposition of the property constitute integral parts of the
regular course of a trade or business operation. (C) "Nonbusiness income" means all income other than
business income and may include, but is not limited to,
compensation, rents and royalties from real or tangible personal
property, capital gains, interest, dividends and distributions,
patent or copyright royalties, or lottery winnings, prizes, and
awards. (D) "Compensation" means any form of remuneration paid to
an employee for personal services. (E) "Fiduciary" means a guardian, trustee, executor,
administrator, receiver, conservator, or any other person acting
in any fiduciary capacity for any individual, trust, or estate. (F) "Fiscal year" means an accounting period of twelve
months ending on the last day of any month other than December. (G) "Individual" means any natural person. (H) "Internal Revenue Code" means the "Internal Revenue
Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. (I) "Resident" means: (1) An individual who is domiciled in this state, subject
to section 5747.24 of the Revised Code; (2) The estate of a decedent who at the time of death
was domiciled in this state. The domicile tests of section
5747.24 of the Revised Code and any election under section
5747.25 of the Revised Code are not controlling for purposes of
division (I)(2) of this section. (J) "Nonresident" means an individual or estate that is
not a resident. An individual who is a resident for only part of
a taxable year is a nonresident for the remainder of that taxable
year. (K) "Pass-through entity" has the same meaning as in section 5733.04 of the
Revised Code. (L) "Return" means the notifications and reports required
to be filed pursuant to this chapter for the purpose of reporting
the tax due and includes declarations of estimated tax when so
required. (M) "Taxable year" means the calendar year or the
taxpayer's fiscal year ending during the calendar year, or
fractional part thereof, upon which the adjusted gross income is
calculated pursuant to this chapter. (N) "Taxpayer" means any person subject to the tax imposed
by section 5747.02 of the Revised Code or any pass-through entity that
makes the election under division (D) of section 5747.08 of the Revised Code. (O) "Dependents" means dependents as defined in the
Internal Revenue Code and as claimed in the taxpayer's federal
income tax return for the taxable year or which the taxpayer
would have been permitted to claim had the taxpayer filed a
federal income
tax return. (P) "Principal county of employment" means, in the case of
a nonresident, the county within the state in which a taxpayer
performs services for an employer or, if those services are
performed in more than one county, the county in which the major
portion of the services are performed. (Q) As used in sections 5747.50 to 5747.55 of the Revised Code: (1) "Subdivision" means any county, municipal corporation,
park district, or township. (2) "Essential local government purposes" includes all
functions that any subdivision is required by general law to
exercise, including like functions that are exercised under a
charter adopted pursuant to the Ohio Constitution. (R) "Overpayment" means any amount already paid that
exceeds the figure determined to be the correct amount of the
tax. (S) "Taxable income" applies to estates only and means
taxable income as defined and used in the Internal Revenue Code
adjusted as follows: (1) Add interest or dividends on obligations or securities
of any state or of any political subdivision or authority of any
state, other than this state and its subdivisions and
authorities; (2) Add interest or dividends on obligations of any
authority, commission, instrumentality, territory, or possession
of the United States that are exempt from federal income taxes
but not from state income taxes; (3) Add the amount of personal exemption allowed to the
estate pursuant to section 642(b) of the Internal Revenue Code; (4) Deduct interest or dividends on obligations of the
United States and its territories and possessions or of any
authority, commission, or instrumentality of the United States
that are exempt from state taxes under the laws of the United
States; (5) Deduct the amount of wages and salaries, if any, not
otherwise allowable as a deduction but that would have been
allowable as a deduction in computing federal taxable income for
the taxable year, had the targeted jobs credit allowed under
sections 38, 51, and 52 of the Internal Revenue Code not been in
effect; (6) Deduct any interest or interest equivalent on public
obligations and purchase obligations to the extent included in
federal taxable income; (7) Add any loss or deduct any gain resulting from sale,
exchange, or other disposition of public obligations to the
extent included in federal taxable income; (8) Except in the case of the final return of an estate,
add any amount deducted by the taxpayer on both its Ohio estate
tax return pursuant to section 5731.14 of the Revised Code, and
on its federal income tax return in determining either federal
adjusted gross income or federal taxable income; (9)(a) Deduct any amount included in federal taxable income
solely because the amount represents a reimbursement or refund of
expenses that in a previous year the decedent had deducted as an
itemized deduction pursuant to section 63 of the Internal Revenue
Code and applicable treasury regulations;.
The deduction otherwise allowed under division
(S)(9)(a)
of this section shall be reduced to the extent the reimbursement is
attributable to an amount the taxpayer or decedent deducted under this section
in any taxable year. (b) Add any amount not otherwise included in Ohio
taxable
income for any taxable year to the extent that the amount is attributable to
the recovery during the taxable year of any amount deducted or excluded in
computing federal or Ohio taxable income in any taxable year. (10) Deduct any portion of the deduction described in
section 1341(a)(2) of the Internal Revenue Code, for repaying
previously reported income received under a claim of right, that
meets both of the following requirements: (a) It is allowable for repayment of an item that was
included in the taxpayer's taxable income or the decedent's
adjusted gross income for a prior taxable year and did not
qualify for a credit under division (A) or (B) of section 5747.05
of the Revised Code for that year. (b) It does not otherwise reduce the taxpayer's taxable
income or the decedent's adjusted gross income for the current or
any other taxable year. (11) Add any amount claimed as a credit under section 5747.059
of the Revised Code to the extent that the amount satisfies
either of the following: (a) The amount was deducted or excluded from the computation of the
taxpayer's federal taxable income as required to be reported for the
taxpayer's taxable year under the Internal Revenue Code; (b) The amount resulted in a reduction in the taxpayer's federal taxable
income as required to be reported for any of the taxpayer's taxable years
under the Internal Revenue Code. (T) "School district income" and "school district income
tax" have the same meanings as in section 5748.01 of the Revised
Code. (U) As used in divisions (A)(8), (A)(9), (S)(6), and
(S)(7) of this section, "public obligations," "purchase
obligations," and "interest or interest equivalent" have the same
meanings as in section 5709.76 of the Revised Code. (V) "Limited liability company" means any limited
liability company formed under Chapter 1705. of the Revised Code
or under the laws of any other state. (W) "Pass-through entity investor" means any person who, during any portion
of a taxable year of a pass-through entity, is a partner, member, shareholder,
or investor in that pass-through entity. (X) "Banking day" has the same meaning as in section 1304.01 of the Revised
Code. (Y) "Month" means a calendar month. (Z) "Quarter" means the first three months, the second three months, the
third three months, or the last three months of the taxpayer's taxable year. (AA) Any term used in this chapter that is not otherwise defined in this
section and that is not used in a comparable context in the
Internal Revenue Code and other statutes of the
United States relating to federal income taxes has the same
meaning as in section 5733.40 of the Revised Code. SECTION 2 . That existing sections 1751.11, 1751.19, 1751.33, 1751.35, 1751.77,
1751.78, 1751.81, 1751.82, 1751.83, 1751.84, 1751.85, 1753.24, and
5747.01 of the Revised Code are hereby repealed.
SECTION 3 . Sections 1 and 2 of this act, except for the
amendment of sections 1751.11, 1751.33, and 5747.01 and the enactment of
sections 1753.13 and 3923.65 of the Revised Code, shall take effect on May 1,
2000. The enactment of section 1753.13 and the amendment of sections 1751.11,
1751.33, and 5747.01 of the Revised Code shall take effect on the effective
date of this section. The enactment of section 3923.65 of the Revised Code
shall take effect 180 days after the effective date of this section.
SECTION 4 . Section 3923.65 of the Revised Code applies only to policies
issued,
issued for delivery, or renewed in this state 180 days after the effective
date of this section and thereafter.
SECTION 5 . The amendment by this act of section 5747.01 of the Revised Code
applies to taxable years beginning on or after January 1, 1999.
SECTION 6 . It is the intent of the General Assembly that sections 1751.84,
1751.85, 3923.67, 3923.68, 3923.76, and 3923.77 of the Revised Code, as
enacted or amended by this act, provide
health insuring corporation enrollees, insureds, and governmental plan members
with a means for resolving health care
coverage disputes expeditiously and avoid the need for lengthy and expensive
litigation.
SECTION 7 . This act shall be known as "The Patient Protection Act of 1999."
|