Ohio Revised Code
Chapter 3901 | Superintendent of Insurance
Section 3901.381 | Third-Party Payers Processing Claims for Payment for Health Care Services.

Effective: October 17, 2019
Latest Legislation: House Bill 166 - 133rd General Assembly
(A) Except as provided in sections 3901.382, 3901.383, 3901.384, and 3901.386 of the Revised Code, a third-party payer shall process a claim for payment for health care services rendered by a provider to a beneficiary in accordance with this section.
(B)(1) Unless division (B)(2) or (3) of this section applies, when a third-party payer receives from a provider or beneficiary a claim on the standard claim form prescribed in rules adopted by the superintendent of insurance under section 3902.22 of the Revised Code, the third-party payer shall pay or deny the claim not later than thirty days after receipt of the claim. When a third-party payer denies a claim, the third-party payer shall notify the provider and the beneficiary. The notice shall state, with specificity, why the third-party payer denied the claim.
(2)(a) Unless division (B)(3) of this section applies, when a provider or beneficiary has used the standard claim form, but the third-party payer determines that reasonable supporting documentation is needed to establish the third-party payer's responsibility to make payment, the third-party payer shall pay or deny the claim not later than forty-five days after receipt of the claim. Supporting documentation includes the verification of employer and beneficiary coverage under a benefits contract, confirmation of premium payment, medical information regarding the beneficiary and the services provided, information on the responsibility of another third-party payer to make payment or confirmation of the amount of payment by another third-party payer, and information that is needed to correct material deficiencies in the claim related to a diagnosis or treatment or the provider's identification.
Not later than thirty days after receipt of the claim, the third-party payer shall notify all relevant external sources that the supporting documentation is needed. All such notices shall state, with specificity, the supporting documentation needed. If the notice was not provided in writing, the provider, beneficiary, or third-party payer may request the third-party payer to provide the notice in writing, and the third-party payer shall then provide the notice in writing. If any of the supporting documentation is under the control of the beneficiary, the beneficiary shall provide the supporting documentation to the third-party payer.
The number of days that elapse between the third-party payer's last request for supporting documentation within the thirty-day period and the third-party payer's receipt of all of the supporting documentation that was requested shall not be counted for purposes of determining the third-party payer's compliance with the time period of not more than forty-five days for payment or denial of a claim. Except as provided in division (B)(2)(b) of this section, if the third-party payer requests additional supporting documentation after receiving the initially requested documentation, the number of days that elapse between making the request and receiving the additional supporting documentation shall be counted for purposes of determining the third-party payer's compliance with the time period of not more than forty-five days.
(b) If a third-party payer determines, after receiving initially requested documentation, that it needs additional supporting documentation pertaining to a beneficiary's preexisting condition, which condition was unknown to the third-party payer and about which it was reasonable for the third-party payer to have no knowledge at the time of its initial request for documentation, and the third-party payer subsequently requests this additional supporting documentation, the number of days that elapse between making the request and receiving the additional supporting documentation shall not be counted for purposes of determining the third-party payer's compliance with the time period of not more than forty-five days.
(c) When a third-party payer denies a claim, the third-party payer shall notify the provider and the beneficiary. The notice shall state, with specificity, why the third-party payer denied the claim.
(d) If a third-party payer determines that supporting documentation related to medical information is routinely necessary to process a claim for payment of a particular health care service, the third-party payer shall establish a description of the supporting documentation that is routinely necessary and make the description available to providers in a readily accessible format.
Third-party payers and providers shall, in connection with a claim, use the most current CPT code in effect, as published by the American medical association, the most current ICD-10 code in effect, as published by the United States department of health and human services, the most current CDT code in effect, as published by the American dental association, or the most current HCPCS code in effect, as published by the United States centers for medicare and medicaid services.
(3) When a provider or beneficiary submits a claim by using the standard claim form prescribed in the superintendent's rules, but the information provided in the claim is materially deficient, the third-party payer shall notify the provider or beneficiary not later than fifteen days after receipt of the claim. The notice shall state, with specificity, the information needed to correct all material deficiencies. Once the material deficiencies are corrected, the third-party payer shall proceed in accordance with division (B)(1) or (2) of this section.
It is not a violation of the notification time period of not more than fifteen days if a third-party payer fails to notify a provider or beneficiary of material deficiencies in the claim related to a diagnosis or treatment or the provider's identification. A third-party payer may request the information necessary to correct these deficiencies after the end of the notification time period. Requests for such information shall be made as requests for supporting documentation under division (B)(2) of this section, and payment or denial of the claim is subject to the time periods specified in that division.
(C) For purposes of this section, if a dispute exists between a provider and a third-party payer as to the day a claim form was received by the third-party payer, both of the following apply:
(1) If the provider or a person acting on behalf of the provider submits a claim directly to a third-party payer by mail and retains a record of the day the claim was mailed, there exists a rebuttable presumption that the claim was received by the third-party payer on the fifth business day after the day the claim was mailed, unless it can be proven otherwise.
(2) If the provider or a person acting on behalf of the provider submits a claim directly to a third-party payer electronically, there exists a rebuttable presumption that the claim was received by the third-party payer twenty-four hours after the claim was submitted, unless it can be proven otherwise.
(D) Nothing in this section requires a third-party payer to provide more than one notice to an employer whose premium for coverage of employees under a benefits contract has not been received by the third-party payer.
(E) Compliance with the provisions of division (B)(3) of this section shall be determined separately from compliance with the provisions of divisions (B)(1) and (2) of this section.
(F) A third-party payer shall transmit electronically any payment with respect to claims that the third-party payer receives electronically and pays to a contracted provider under this section and under sections 3901.383, 3901.384, and 3901.386 of the Revised Code. A provider shall not refuse to accept a payment made under this section or sections 3901.383, 3901.384, and 3901.386 of the Revised Code on the basis that the payment was transmitted electronically.

Structure Ohio Revised Code

Ohio Revised Code

Title 39 | Insurance

Chapter 3901 | Superintendent of Insurance

Section 3901.01 | Department of Insurance.

Section 3901.011 | Superintendent of Insurance - Powers and Duties.

Section 3901.02 | Appointment or Hiring of Employees.

Section 3901.021 | Department of Insurance Operating Fund.

Section 3901.03 | Warden - Duties - Office of Warden.

Section 3901.04 | Superintendent - Specific Powers.

Section 3901.041 | Rule-Making and Adjudicating Powers of Superintendent.

Section 3901.042 | Service and Transaction Fees.

Section 3901.043 | Fees for Services or Transactions Performed by Department of Insurance.

Section 3901.044 | Rules for Implementing Health Insurance Portability and Accountability Act.

Section 3901.045 | Receiving Confidential or Privileged Documents and Information.

Section 3901.046 | Electronic Signatures.

Section 3901.05 | Deputy Superintendent - Duties.

Section 3901.051 | Assistant Superintendent - Duties.

Section 3901.052 | Application for Innovative Waiver.

Section 3901.06 | Instruments Under Seal of the Superintendent.

Section 3901.07 | Examination of Financial Affairs of Insurer.

Section 3901.071 | Superintendent's Examination Fund.

Section 3901.072 | Corporate Governance Annual Disclosure Act.

Section 3901.073 | Corporate Governance Annual Disclosure.

Section 3901.074 | Format of Disclosure.

Section 3901.075 | Documents Deemed Proprietary.

Section 3901.076 | Retention of Third-Party Consultant.

Section 3901.077 | Rules.

Section 3901.078 | Penalty.

Section 3901.08 | Information From Banks.

Section 3901.09 | Duty of Bank Officers.

Section 3901.10 | Deficiency of Company Assets.

Section 3901.11 | Acquisition of Stock of Other Insurers.

Section 3901.12 | Interlocking Directorate.

Section 3901.13 | Hearing by Superintendent.

Section 3901.14 | Record and Report of Superintendent.

Section 3901.15 | Application of Law.

Section 3901.16 | Forfeiture.

Section 3901.17 | Personal Jurisdiction Over Foreign or Alien Insurer.

Section 3901.18 | Requirements for Unauthorized Foreign or Alien Insurer to Enter an Appearance.

Section 3901.19 | Unfair and Deceptive Practices Definitions.

Section 3901.20 | Prohibition Against Unfair or Deceptive Acts.

Section 3901.21 | Unfair and Deceptive Acts or Practices in Business of Insurance Defined.

Section 3901.211 | Lending of Money, Extension of Credit - Prohibited Acts.

Section 3901.212 | Consumer Protection Rules.

Section 3901.213 | Unfair and Deceptive Practices - Exceptions.

Section 3901.214 | Applicability of Prohibition on Inducements.

Section 3901.215 | Intent to Promote Innovation and Maintain Strong Consumer Protection.

Section 3901.22 | Hearings on Violation - Orders - Administrative Remedies.

Section 3901.221 | Cease-and-Desist Orders.

Section 3901.23 | Self-Incrimination.

Section 3901.24 | Unlawful Advertising.

Section 3901.241 | List of Top Twenty per Cent of Services and Expected Contributions.

Section 3901.25 | Action by Superintendent Against Insurer.

Section 3901.26 | Acts by Insurer Which Constitute Appointment of Superintendent as Attorney - Service of Statement.

Section 3901.27 | Adoption of Emergency Bylaws.

Section 3901.28 | Provisions Effective if No Emergency Bylaws.

Section 3901.29 | Succession List.

Section 3901.30 | Emergency Business Location.

Section 3901.31 | Filing Statements Indicating Ownership.

Section 3901.32 | Insurance Holding Company System Definitions.

Section 3901.321 | Mergers and Acquisitions of Domestic Insurers.

Section 3901.322 | Procedure for Violations.

Section 3901.323 | Jurisdiction.

Section 3901.33 | Registration; Enterprise Risk Report; Group Capital Calculation; Liquidity Stress Test.

Section 3901.34 | Transactions to Which Insurer Is a Party; Dividends and Distributions to Shareholders.

Section 3901.341 | Prior Review of Proposed Transactions.

Section 3901.35 | Requiring Production of Records.

Section 3901.351 | Participation in Supervisory College.

Section 3901.352 | Group-Wide Supervisor for Internationally Active Insurance Group.

Section 3901.36 | Confidential and Privileged Treatment of Documents and Information - Exceptions.

Section 3901.37 | Suspension, Revocation or Refusal to Renew License - Civil Forfeiture.

Section 3901.371 | Purpose of Sections 3901.371 to 3901.378.

Section 3901.372 | Definitions.

Section 3901.373 | Risk Management Framework.

Section 3901.374 | Own Risk and Solvency Assessment.

Section 3901.375 | Summary Report.

Section 3901.376 | Exemptions.

Section 3901.377 | Form and Content of Report; Review.

Section 3901.378 | Confidentiality.

Section 3901.38 | Prompt Payments to Health Care Providers Definitions.

Section 3901.381 | Third-Party Payers Processing Claims for Payment for Health Care Services.

Section 3901.382 | Electronic Submission of Claims.

Section 3901.383 | Contractual Agreements for Payments by Third-Party Payers.

Section 3901.384 | Untimely Claim Process.

Section 3901.385 | Third-Party Payer - Prohibited Acts.

Section 3901.386 | Reimbursement Contract - Reimbursements to Be Made Directly to Hospital - Assignment of Benefits.

Section 3901.387 | Duplicative Claims - Claim Information System.

Section 3901.388 | Payments Considered Final - Overpayment.

Section 3901.389 | Computation of Interest.

Section 3901.3810 | Complaints by Provider or Beneficiary - Retaliation by Payer.

Section 3901.3811 | Failure to Comply by Third-Party Payer.

Section 3901.3812 | Administrative Remedies.

Section 3901.3813 | Rules.

Section 3901.3814 | Exceptions to Provisions.

Section 3901.40 | Payment or Reimbursement to Unlicensed or Unaccredited Hospital Prohibited.

Section 3901.41 | Applicability of Uniform Electronics Transactions Act; Automated Transactions.

Section 3901.42 | Annual Filing With National Association of Insurance Commissioners.

Section 3901.44 | Records of Insurance Fraud Investigation.

Section 3901.45 | Effect of Sexual Orientation, Hiv, or AIDS or Related Condition.

Section 3901.46 | Requiring HIV Testing.

Section 3901.47 | Administration of Claims Unpaid Due to Insolvency of Insurer.

Section 3901.48 | Disclosing Work Papers Resulting From Conduct of Audit.

Section 3901.491 | Genetic Screening or Testing.

Section 3901.501 | Genetic Screening or Testing for Self-Insurance Plans.

Section 3901.51 | Uncertified Securities as Deposits Definitions.

Section 3901.52 | Insurance Company May Place Securities in Clearing Corporation or Federal Reserve Book-Entry System.

Section 3901.53 | Placement of Securities Shall Satisfy Deposit Requirements.

Section 3901.54 | Securities May Not Be Used for Other Purposes.

Section 3901.55 | Rules.

Section 3901.56 | Rewards or Incentives for Insurer Wellness or Health Improvement Programs.

Section 3901.61 | Credit for Reinsurance Ceded Definitions.

Section 3901.62 | Credit for Reinsurance Ceded as Asset or Reduction of Liability; Accreditation as Reinsurer.

Section 3901.621 | Suspension or Revocation of Reinsurer's Accreditation or Certification.

Section 3901.63 | Credit for Reinsurance Ceded as Reduction of Liability.

Section 3901.631 | Management of Reinsurance Recoverables by Domestic Ceding Insurer.

Section 3901.64 | Terms of Reinsurance or Security Agreement.

Section 3901.65 | Rules.

Section 3901.67 | Disclosure of Material Transactions Model Act Definitions.

Section 3901.68 | Provisions Application.

Section 3901.69 | Insurer to Report Material Transactions.

Section 3901.70 | Confidentiality of Reports - Exceptions.

Section 3901.71 | Application of Mandated Health Benefits.

Section 3901.72 | Money Advanced to Insurance Company or Health Insuring Corporation.

Section 3901.73 | Department to Forward Copy of Late Filing Notice to Board of Directors.

Section 3901.74 | Notice of Life Insurance Company Discontinuing Business.

Section 3901.75 | Notice of Insurance Companies Other Than Life Discontinuing Business.

Section 3901.76 | Security Valuation Expense Fund.

Section 3901.77 | Forms, Instructions, Manuals - Determination of Accounting Practices and Methods.

Section 3901.78 | Certificate of Compliance.

Section 3901.80 | Discriminating Against Living Organ Donors.

Section 3901.81 | Definitions.

Section 3901.811 | Pharmacy Audits.

Section 3901.812 | Rights of Pharmacy.

Section 3901.813 | Proceedings After Audit.

Section 3901.814 | Appeal Process.

Section 3901.815 | Applicability of Provisions.

Section 3901.82 | Restatement of the Law, Liability Insurance.

Section 3901.83 | Definitions for Sections 3901.83 to 3901.833.

Section 3901.831 | Implementation of Step Therapy Protocol.

Section 3901.832 | Step Therapy Exemption.

Section 3901.833 | Adoption of Rules.

Section 3901.86 | Retaliatory Provisions - Moneys Collected Paid to State Fire Marshal's Fund.

Section 3901.87 | No Coverage for Nontherapeutic Abortion.

Section 3901.88 | Actuarial Study Regarding Costs of Health Care Mandates.

Section 3901.89 | Health Plan Issuers Release Claim Information to Group Plan policyholders..

Section 3901.90 | Education on Mental Health and Addiction Services Insurance Parity.

Section 3901.91 | Adoption or Amendment of Rules Related to Insurance Rating Agencies.

Section 3901.95 | Direct Primary Care Agreement Not to Be Considered Insurance.

Section 3901.99 | Penalty.