Except for when an expedited request is made under section 3922.09 or 3922.10 of the Revised Code, an independent review organization shall forward upon receipt a copy of any information received from a covered person pursuant to division (D)(1) of section 3922.05 of the Revised Code, as well as any other information received from the covered person, to the health plan issuer.

Terms Used In Ohio Code 3922.06

  • 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
  • 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
  • Person: includes an individual, corporation, business trust, estate, trust, partnership, and association. See Ohio Code 1.59
  • Superintendent: means the superintendent of insurance. See Ohio Code 3922.01

Upon receipt of that information or the information described in division (K) of section 3922.10 of the Revised Code, a health plan issuer may reconsider its adverse benefit determination and provide coverage for the health service in question.

Reconsideration of an adverse benefit determination by a health plan issuer based upon receipt of information under this section shall not delay or terminate an external review.

If a health plan issuer reverses an adverse benefit determination under this section, the health plan issuer shall notify, in writing and within one business day of making such a decision, the covered person, the assigned independent review organization, and the superintendent of insurance.

Upon receipt of such a notification, the assigned independent review organization shall terminate the associated external review.

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