Ohio Code 1751.77 – Utilization review, internal and external review procedure definitions
As used in sections 1751.77 to 1751.87 of the Revised Code, unless otherwise specifically provided or as otherwise required pursuant to applicable federal law or regulations:
Terms Used In Ohio Code 1751.77
- Another: when used to designate the owner of property which is the subject of an offense, includes not only natural persons but also every other owner of property. See Ohio Code 1.02
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: means a corporation formed under Chapter 1701. 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.
- Enrollee: means any natural person who is entitled to receive health care benefits provided by a health insuring corporation. See Ohio Code 1751.01
- Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
- Health care facility: means any facility, except a health care practitioner's office, that provides preventive, diagnostic, therapeutic, acute convalescent, rehabilitation, mental health, intellectual disability, intermediate care, or skilled nursing services. 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
- Person: includes an individual, corporation, business trust, estate, trust, partnership, and association. See Ohio Code 1.59
- Provider: means any natural person or partnership of natural persons who are licensed, certified, accredited, or otherwise authorized in this state to furnish health care services, or any professional association organized under Chapter 1785 of the Revised Code, provided that nothing in this chapter or other provisions of law shall be construed to preclude a health insuring corporation, health care practitioner, or organized health care group associated with a health insuring corporation from employing certified nurse practitioners, certified nurse anesthetists, clinical nurse specialists, certified nurse-midwives, pharmacists, dietitians, physician assistants, dental assistants, dental hygienists, optometric technicians, or other allied health personnel who are licensed, certified, accredited, or otherwise authorized in this state to furnish health care services. See Ohio Code 1751.01
- state: means the state of Ohio. See Ohio Code 1.59
(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 has been reviewed and, based upon the information provided, the health care service does not meet the 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.
(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 has been reviewed and, based upon the information provided, the health care service satisfies the requirements for benefit payment under the health insuring corporation’s policy, contract, or agreement.
(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.
(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.
(H) “Concurrent review” means utilization review conducted during a patient’s hospital stay or course of treatment.
(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.
(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.
(K) “Physician” means a provider who holds a license issued under Chapter 4731 of the Revised Code authorizing the practice of medicine and surgery or osteopathic medicine and surgery or a comparable license from another state.
(L) “Prospective review” means utilization review that is conducted prior to an admission or a course of treatment.
(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.
(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.
(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.
(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.