Effective: July 17, 2009
Latest Legislation: House Bill 1 - 128th General Assembly
(A) If, after completion of an examination involving information collected from a six-month period, the superintendent finds that a third-party payer has committed a series of violations that, taken together, constitutes a consistent pattern or practice of violating division (A) of section 3901.3811 of the Revised Code, the superintendent may impose on the third-party payer any of the administrative remedies specified in division (B) of this section. In making a finding under this division, the superintendent shall apply the error tolerance standards for claims processing contained in the market conduct examiners handbook issued by the national association of insurance commissioners in effect at the time the claims were processed.
Before imposing an administrative remedy, the superintendent shall provide written notice to the third-party payer informing the third-party payer of the reasons for the superintendent's finding, the administrative remedy the superintendent proposes to impose, and the opportunity to submit a written request for an administrative hearing regarding the finding and proposed remedy. If the third-party payer requests a hearing, the superintendent shall conduct the hearing in accordance with Chapter 119. of the Revised Code not later than fifteen days after receipt of the request.
(B)(1) In imposing administrative remedies under division (A) of this section for violations of section 3901.381 of the Revised Code, the superintendent may do any of the following:
(a) Levy a monetary penalty in an amount determined in accordance with division (B)(3) of this section;
(b) Order the payment of interest directly to the provider in accordance with section 3901.389 of the Revised Code;
(c) Order the third-party payer to cease and desist from engaging in the violations;
(d) If a monetary penalty is not levied under division (B)(1)(a) of this section, impose any of the administrative remedies provided for in section 3901.22 of the Revised Code, other than those specified in divisions (D)(4) and (5) and (G) of that section.
(2) In imposing administrative remedies under division (A) of this section for violations of sections 3901.384 to 3901.3810 of the Revised Code, the superintendent may do any of the following:
(a) Levy a monetary penalty in an amount determined in accordance with division (B)(3) of this section;
(b) Order the payment of interest directly to the provider in accordance with section 3901.38 of the Revised Code;
(c) Order the third-party payer to cease and desist from engaging in the violations;
(d) If a monetary penalty is not levied under division (B)(2)(a) of this section, impose any of the administrative remedies provided for in section 3901.22 of the Revised Code, other than those specified in divisions (D)(4) and (5) and (G) of that section. For violations of sections 3901.384 to 3901.3810 of the Revised Code that did not comply with section 3901.381 of the Revised Code, the superintendent may also use section 3901.22 of the Revised Code except divisions (D)(4) and (5) of that section.
(3) A finding by the superintendent that a third-party payer has committed a series of violations that, taken together, constitutes a consistent pattern or practice of violating division (A) of section 3901.3811 of the Revised Code, shall constitute a single offense for purposes of levying a fine under division (B)(1)(a) and (B)(2)(a) of this section. For a first offense, the superintendent may levy a fine of not more than one hundred thousand dollars. For a second offense that occurs on or earlier than four years from the first offense, the superintendent may levy a fine of not more than one hundred fifty thousand dollars. For a third or additional offense that occurs on or earlier than seven years after a first offense, the superintendent may levy a fine of not more than three hundred thousand dollars. In determining the amount of a fine to be levied within the specified limits, the superintendent shall consider the following factors:
(a) The extent and frequency of the violations;
(b) Whether the violations were due to circumstances beyond the third-party payer's control;
(c) Any remedial actions taken by the third-party payer to prevent future violations;
(d) The actual or potential harm to others resulting from the violations;
(e) If the third-party payer knowingly and willingly committed the violations;
(f) The third-party payer's financial condition;
(g) Any other factors the superintendent considers appropriate.
(C) The remedies imposed by the superintendent under this section are in addition to, and not in lieu of, such other remedies as providers and beneficiaries may otherwise have by law.
(D) Any fine collected under this section shall be paid into the state treasury as follows:
(1) Twenty-five per cent of the total to the credit of the department of insurance operating fund created by section 3901.021 of the Revised Code;
(2) Sixty-five per cent of the total to the credit of the general revenue fund;
(3) Ten per cent of the total to the credit of claims processing education account, which is hereby created within the department of insurance operating fund created by section 3901.021 of the Revised Code.
All money credited to the claims processing education account shall be used by the department of insurance to make technical assistance available to third-party payers, providers, and beneficiaries for effective implementation of the provisions of sections 3901.38 and 3901.381 to 3901.3814 of the Revised Code.
Structure Ohio Revised Code
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 3901.08 | 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 3901.17 | 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 3901.27 | 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 3901.341 | 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 3901.387 | 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 3901.3814 | 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 3901.53 | Placement of Securities Shall Satisfy Deposit Requirements.
Section 3901.54 | Securities May Not Be Used for Other Purposes.
Section 3901.56 | Rewards or Incentives for Insurer Wellness or Health Improvement Programs.
Section 3901.61 | Credit for Reinsurance Ceded Definitions.
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 3901.67 | 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.