Ohio Code 3922.09 – Request for expedited external review
(A) A covered person may make a request for an expedited external review, except as provided in division (I) of this section:
Terms Used In Ohio Code 3922.09
- 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
- 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
- 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
- Uphold: The decision of an appellate court not to reverse a lower court decision.
(1) After an adverse benefit determination, if both of the following apply:
(a) The covered person‘s treating physician certifies that the adverse benefit determination involves a medical condition that could seriously jeopardize the life or health of the covered person, or would jeopardize the covered person’s ability to regain maximum function, if treated after the time frame of an expedited internal appeal;
(b) The covered person has filed a request for an expedited internal appeal.
(2) After a final adverse benefit determination, if either of the following apply:
(a) The covered person’s treating physician certifies that the adverse benefit determination involves a medical condition that could seriously jeopardize the life or health of the covered person, or would jeopardize the covered person’s ability to regain maximum function, if treated after the time frame of a standard external review;
(b) The final adverse benefit determination concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services, but has not yet been discharged from a facility.
(B) Immediately upon receipt of a request for an expedited external review, the health plan issuer shall determine if the request is complete under any associated rules, policies, or procedures adopted by the superintendent of insurance and eligible for expedited external review under division (A) of this section. The health plan issuer shall immediately notify the covered person of its determination in accordance with any associated rules, policies, or procedures adopted by the superintendent of insurance.
(C) If a request for an expedited review is complete and eligible, the health plan issuer shall immediately provide or transmit all necessary documents and information considered in making the adverse benefit determination in question to the assigned independent review organization electronically, or by facsimile or other available expeditious method.
(D) In addition to the information transmitted under division (C) of this section, the assigned independent review organization shall also consider relevant information as required under section 3922.07 of the Revised Code.
(E) As expeditiously as the covered person’s medical condition requires, but no more than seventy-two hours after receipt by the health plan issuer of a request for an expedited, external review, the assigned independent review organization shall uphold or reverse the adverse benefit determination.
(F) If a health plan issuer fails to provide the documents and information as required in division (C) of this section, the independent review organization shall not delay the external review and may accordingly reverse the adverse benefit determination.
(G) An independent review organization shall promptly notify the covered person, health plan issuer, and superintendent of insurance of any decision made under this section. If such a notice is not made in writing, the independent review organization, shall provide, within forty-eight hours of making the decision, written confirmation, including the information required under division (H)(3) of section 3922.05 of the Revised Code, of its decision to the covered person, the health plan issuer, and the superintendent of insurance.
(H) Upon receipt of a notice by an independent review organization to reverse the adverse benefit determination, a health plan issuer shall immediately provide coverage for the health care service or services in question.
(I) An expedited, external review may not be provided for retrospective final adverse benefit determinations.