Ohio Code 3922.12 – Effect of decision
(A) An external review decision is binding on the health plan issuer except to the extent the health plan issuer has other remedies available under applicable state law, or unless the superintendent of insurance determines that, due to the facts and circumstances of an external review, a second external review is required.
Terms Used In Ohio Code 3922.12
- 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
- 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.
- 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
- state: means the state of Ohio. See Ohio Code 1.59
- Superintendent: means the superintendent of insurance. See Ohio Code 3922.01
(B) An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or state law, or unless the superintendent determines that, due to the facts and circumstances of an external review, a second external review is required.
(C) A covered person may not file a subsequent request for external review involving the same adverse benefit determination for which the covered person has already received an external review decision pursuant to this chapter, except in the event that new medical or scientific evidence is submitted to the health plan issuer.