Effective: December 26, 2011
Latest Legislation: House Bill 218 - 129th General Assembly
(A) The provisions of this section apply only to standard reviews, which are not expedited and do not involve an experimental or investigational treatment.
(B) Within five days after the receipt of a request for an external review that is complete and valid, the health plan issuer shall provide to the assigned independent review organization all documents and information considered in making the adverse benefit determination.
(C) An external review shall not be delayed due to failure on the part of the health plan issuer to provide the information required under division (B) of this section.
(D)(1) An independent review organization may reverse an adverse benefit determination if the information required under division (B) of this section is not provided in the allotted time. The independent review organization may also grant a request from the health plan issuer for more time to provide the required information.
(2) If an adverse benefit determination is reversed under division (D)(1) of this section, the independent review organization shall notify, within one business day of making the decision, the covered person, the health plan issuer, and the superintendent of insurance.
Structure Ohio Revised Code
Chapter 3922 | External Review
Section 3922.01 | Definitions.
Section 3922.02 | Request for Review of Adverse Benefit Determination.
Section 3922.03 | Internal Appeal Processes; Review of Final Determination.
Section 3922.04 | Exhaustion of Issuer's Internal Appeal Process.
Section 3922.05 | Opportunities for External Review by Independent Review Organization.
Section 3922.06 | Reconsideration by Issuer.
Section 3922.07 | Information Considered for Review.
Section 3922.08 | Provisions Applicable to Standard Reviews; Timing;.
Section 3922.09 | Request for Expedited External Review.
Section 3922.11 | Review by Superintendent of Insurance.
Section 3922.12 | Effect of Decision.
Section 3922.13 | Accreditation of Independent Review Organizations.
Section 3922.14 | Additional Actions for Accreditation.
Section 3922.15 | Qualifications for Clinical Reviewers.
Section 3922.16 | Construction of Chapter; Limitations on Liability.
Section 3922.17 | Maintenance of Records; Reports.
Section 3922.18 | Payment of Costs.
Section 3922.19 | Disclosure of External Review Procedures.
Section 3922.20 | Admissibility of Written Decision or Medicare Reimbursement Standards.
Section 3922.21 | Confidentiality.