Ohio Code 3922.08 – Provisions applicable to standard reviews; Timing;
(A) The provisions of this section apply only to standard reviews, which are not expedited and do not involve an experimental or investigational treatment.
Terms Used In Ohio Code 3922.08
- Adverse benefit determination: means a decision by a health plan issuer:
(1) To deny, reduce, or terminate a requested health care service or payment in whole or in part, including all of the following:
(a) A determination that the health care service does not meet the health plan issuer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, including experimental or investigational treatments;
(b) A determination of an individual's eligibility for individual health insurance coverage, including coverage offered to individuals through a nonemployer group, to participate in a plan or health insurance coverage;
(c) A determination that a health care service is not a covered benefit;
(d) The imposition of an exclusion, including exclusions for pre-existing conditions, source of injury, network, or any other limitation on benefits that would otherwise be covered. See Ohio Code 3922.01
- Covered person: means a policyholder, subscriber, enrollee, member, or individual covered by a health benefit plan. 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
- Superintendent: means the superintendent of insurance. See Ohio Code 3922.01
(B) Within five days after the receipt of a request for an external review that is complete and valid, the health plan issuer shall provide to the assigned independent review organization all documents and information considered in making the adverse benefit determination.
(C) An external review shall not be delayed due to failure on the part of the health plan issuer to provide the information required under division (B) of this section.
(D)(1) An independent review organization may reverse an adverse benefit determination if the information required under division (B) of this section is not provided in the allotted time. The independent review organization may also grant a request from the health plan issuer for more time to provide the required information.
(2) If an adverse benefit determination is reversed under division (D)(1) of this section, the independent review organization shall notify, within one business day of making the decision, the covered person, the health plan issuer, and the superintendent of insurance.