Ohio Code 1751.78 – Application of provisions
(A)(1) Sections 1751.77 to 1751.87 and Chapter 3922. 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 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 covering basic health care services.
Terms Used In Ohio Code 1751.78
- Basic health care services: means the following services when medically necessary:
(a) Physician's services, except when such services are supplemental under division (B) of this section;
(b) Inpatient hospital services;
(c) Outpatient medical services;
(d) Emergency health services;
(e) Urgent care services;
(f) Diagnostic laboratory services and diagnostic and therapeutic radiologic services;
(g) Diagnostic and treatment services, other than prescription drug services, for biologically based mental illnesses;
(h) Preventive health care services, including, but not limited to, voluntary family planning services, infertility services, periodic physical examinations, prenatal obstetrical care, and well-child care;
(i) Routine patient care for patients enrolled in an eligible cancer clinical trial pursuant to section 3923. See Ohio Code 1751.01
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Corporation: means a corporation formed under Chapter 1701. See Ohio Code 1751.01
- Health care services: means basic, supplemental, and specialty health care services. See Ohio Code 1751.01
- Health insuring corporation: means a corporation, as defined in division (H) of this section, that, pursuant to a policy, contract, certificate, or agreement, pays for, reimburses, or provides, delivers, arranges for, or otherwise makes available, basic health care services, supplemental health care services, or specialty health care services, or a combination of basic health care services and either supplemental health care services or specialty health care services, through either an open panel plan or a closed panel plan. See Ohio Code 1751.01
- Specialty health care services: means one of the supplemental health care services listed in division (B) of this section, when provided by a health insuring corporation on an outpatient-only basis and not in combination with other supplemental health care services. See Ohio Code 1751.01
(2) Nothing in sections 1751.77 to 1751.82 or section 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 1751.87 and Chapter 3922 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 1751.87 and Chapter 3922 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.