(A) A covered person may make a request for an external review of an adverse benefit determination.

Terms Used In Ohio Code 3922.02

  • 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.
  • Covered person: means a policyholder, subscriber, enrollee, member, or individual covered by a health benefit plan. 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
  • Health plan issuer: includes a third party administrator licensed under Chapter 3959. See Ohio Code 3922.01
  • Person: includes an individual, corporation, business trust, estate, trust, partnership, and association. See Ohio Code 1.59

(B) All requests for external review shall be made in writing, including by electronic means, by the covered person to the health plan issuer within one hundred eighty days of the date of the final adverse benefit determination. However, in the case of an expedited external review under section 3922.09 of the Revised Code, the review may be requested orally.

(C) An adverse benefit determination shall be eligible for internal appeal or external review, regardless of the cost of the requested health care service related to the adverse benefit determination.

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