Ohio Code 3922.07 – Information considered for review
In addition to the information provided under division (D)(1)(b) of section 3922.05, division (B) of section 3922.08, division (C) of section 3922.09, and division (D) of section 3922.10 of the Revised Code, an assigned independent review organization, to the extent that such documents are available and appropriate, shall consider all of the following when conducting its review:
Terms Used In Ohio Code 3922.07
- Covered person: means a policyholder, subscriber, enrollee, member, or individual covered by a health benefit plan. See Ohio Code 3922.01
- Health care professional: means a physician, psychologist, nurse practitioner, or other health care practitioner licensed, accredited, or certified to perform health care services consistent with state law. See Ohio Code 3922.01
- Health plan issuer: includes a third party administrator licensed under Chapter 3959. See Ohio Code 3922.01
- Independent review organization: means an entity that is accredited to conduct independent external reviews of adverse benefit determinations pursuant to section 3922. See Ohio Code 3922.01
- Person: includes an individual, corporation, business trust, estate, trust, partnership, and association. See Ohio Code 1.59
- provider: means a health care professional or facility. See Ohio Code 3922.01
(A) The covered person‘s medical records;
(B) The attending health care professional‘s recommendation;
(C) Consulting reports from appropriate health care professionals and other documents submitted by the health plan issuer, covered person, or covered person’s treating provider;
(D) The terms of coverage under the covered person’s health benefit plan to ensure that the independent review organization‘s decision is not contrary to the terms of the plan;
(E) The most appropriate practice guidelines, including evidence-based standards, and practice guidelines developed by the federal government, and national or professional medical societies, boards, and associations;
(F) Any applicable clinical review criteria developed and used by the health plan issuer or its designated utilization review organization;
(G) The opinion of the independent review organization’s clinical reviewer or reviewers after considering the other sources described in this section.