Terms Used In Ohio Code > Chapter 3922 - External Review

• 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

• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• benefits: means those health care services to which a covered person is entitled under the terms of a health benefit plan. See Ohio Code 3922.01
• Best evidence: means evidence based on all of the following sources, listed according to priority, as they are available:

  (1) Randomized clinical trials;

  (2) Cohort studies or case-control studies;

  (3) Case series;

  (4) Expert opinion. See Ohio Code 3922.01

• Contract: A legal written agreement that becomes binding when signed.
• 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.
• Covered person: means a policyholder, subscriber, enrollee, member, or individual covered by a health benefit plan. See Ohio Code 3922.01
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
• Evidence-based standard: means the conscientious, explicit, and judicious use of the current best evidence, based on a systematic review of the relevant research, in making decisions about the care of individuals. See Ohio Code 3922.01
• Facility: means an institution providing health care services, or a health care setting, including hospitals and other licensed inpatient centers, ambulatory, surgical, treatment, skilled nursing, residential treatment, diagnostic, laboratory, and imaging centers, and rehabilitation and other therapeutic health settings. See Ohio Code 3922.01
• Final adverse benefit determination: means an adverse benefit determination that is upheld at the completion of a health plan issuer's internal appeals process. See Ohio Code 3922.01
• Germane: On the subject of the pending bill or other business; a strict standard of relevance.
• Health benefit plan: means a policy, contract, certificate, or agreement offered by a health plan issuer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including benefit plans marketed in the individual or group market by all associations, whether bona fide or non-bona fide. 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 care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Ohio Code 3922.01
• Health information: means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relates to all of the following:

  (1) The past, present, or future physical, mental, or behavioral health or condition of a covered person or a member of the covered person's family;

  (2) The provision of health care services or health-related benefits to a covered person;

  (3) Payment for the provision of health care services to or for a covered person. See Ohio Code 3922.01

• Health plan issuer: includes a third party administrator licensed under Chapter 3959. See Ohio Code 3922.01
• in writing: includes any representation of words, letters, symbols, or figures; this provision does not affect any law relating to signatures. See Ohio Code 1.59
• 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
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Medical or scientific evidence: means evidence found in any of the following sources:

  (1) Peer-reviewed scientific studies published in, or accepted for publication by, medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;

  (2) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the national institutes of health's library of medicine for indexing in index medicus and elsevier science ltd. See Ohio Code 3922.01

• Minority leader: See Floor Leaders
• Person: includes an individual, corporation, business trust, estate, trust, partnership, and association. See Ohio Code 1.59
• Property: means real and personal property. See Ohio Code 1.59
• Prosecute: To charge someone with a crime. A prosecutor tries a criminal case on behalf of the government.
• provider: means a health care professional or facility. See Ohio Code 3922.01
• Rescind: means to retroactively cancel or discontinue coverage. See Ohio Code 3922.01
• Retrospective review: means a review conducted after services have been provided to a covered person. See Ohio Code 3922.01
• Rule: includes regulation. See Ohio Code 1.59
• state: means the state of Ohio. See Ohio Code 1.59
• Superintendent: means the superintendent of insurance. See Ohio Code 3922.01
• United States: includes all the states. See Ohio Code 1.59
• Uphold: The decision of an appellate court not to reverse a lower court decision.