3923.66 Review of denials of health care coverage.
(A) As used in sections 3923.66 to 3923.70 of the Revised Code:
(1) “Clinical peer” and “physician” have the same meanings as in section 1751.77 of the Revised Code.
(2) “Authorized person” means a parent, guardian, or other person authorized to act on behalf of an insured with respect to health care decisions.
(B) Sections 3923.66 to 3923.70 of the Revised Code do not apply to any individual or group policy of sickness and accident insurance covering only accident, credit, dental, disability income, long-term care, hospital indemnity, medicare supplement, medicare, tricare, specified disease, or vision care; coverage issued as a supplement to liability insurance; insurance arising out of workers’ compensation or similar law; automobile medical payment insurance; or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
(C) The superintendent of insurance shall establish and maintain a system for receiving and reviewing requests for review from insureds who have been denied coverage of a health care service on the grounds that the service is not a service covered under the terms of the insured’s policy or certificate.
On receipt of a written request from an insured or authorized person, the superintendent shall consider whether the health care service is a service covered under the terms of the insured’s policy or certificate, except that the superintendent shall not conduct a review under this section unless the insured has exhausted the insurer’s internal review process. The insurer and the insured or authorized person shall provide the superintendent with any information required by the superintendent that is in their possession and is germane to the review.
Unless the superintendent is not able to do so because making the determination requires resolution of a medical issue, the superintendent shall determine whether the health care service at issue is a service covered under the terms of the insured’s policy or certificate. The superintendent shall notify the insured, or authorized person, and the insurer of its determination or that it is not able to make a determination because the determination requires the resolution of a medical issue.
If the superintendent notifies the insurer that making the determination requires the resolution of a medical issue, the insurer shall initiate an external review under section 3923.67 or 3923.68 of the Revised Code. If the superintendent notifies the insurer that the health care service is not a covered service, the insurer is not required to cover the service or afford the insured an external review.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
3923.66 Review of denials of health care coverage.
(A) As used in sections 3923.66 to 3923.70 of the Revised Code:
(1) “Clinical peer” and “physician” have the same meanings as in section 1751.77 of the Revised Code.
(2) “Authorized person” means a parent, guardian, or other person authorized to act on behalf of an insured with respect to health care decisions.
(B) Sections 3923.66 to 3923.70 of the Revised Code do not apply to any individual or group policy of sickness and accident insurance covering only accident, credit, dental, disability income, long-term care, hospital indemnity, medicare supplement, medicare, tricare, specified disease, or vision care; coverage issued as a supplement to liability insurance; insurance arising out of workers’ compensation or similar law; automobile medical payment insurance; or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
(C) The superintendent of insurance shall establish and maintain a system for receiving and reviewing requests for review from insureds who have been denied coverage of a health care service on the grounds that the service is not a service covered under the terms of the insured’s policy or certificate.
On receipt of a written request from an insured or authorized person, the superintendent shall consider whether the health care service is a service covered under the terms of the insured’s policy or certificate, except that the superintendent shall not conduct a review under this section unless the insured has exhausted the insurer’s internal review process. The insurer and the insured or authorized person shall provide the superintendent with any information required by the superintendent that is in their possession and is germane to the review.
Unless the superintendent is not able to do so because making the determination requires resolution of a medical issue, the superintendent shall determine whether the health care service at issue is a service covered under the terms of the insured’s policy or certificate. The superintendent shall notify the insured, or authorized person, and the insurer of its determination or that it is not able to make a determination because the determination requires the resolution of a medical issue.
If the superintendent notifies the insurer that making the determination requires the resolution of a medical issue, the insurer shall initiate an external review under section 3923.67 or 3923.68 of the Revised Code. If the superintendent notifies the insurer that the health care service is not a covered service, the insurer is not required to cover the service or afford the insured an external review.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
3923.66 Review of denials of health care coverage.
(A) As used in sections 3923.66 to 3923.70 of the Revised Code:
(1) “Clinical peer” and “physician” have the same meanings as in section 1751.77 of the Revised Code.
(2) “Authorized person” means a parent, guardian, or other person authorized to act on behalf of an insured with respect to health care decisions.
(B) Sections 3923.66 to 3923.70 of the Revised Code do not apply to any individual or group policy of sickness and accident insurance covering only accident, credit, dental, disability income, long-term care, hospital indemnity, medicare supplement, medicare, tricare, specified disease, or vision care; coverage issued as a supplement to liability insurance; insurance arising out of workers’ compensation or similar law; automobile medical payment insurance; or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
(C) The superintendent of insurance shall establish and maintain a system for receiving and reviewing requests for review from insureds who have been denied coverage of a health care service on the grounds that the service is not a service covered under the terms of the insured’s policy or certificate.
On receipt of a written request from an insured or authorized person, the superintendent shall consider whether the health care service is a service covered under the terms of the insured’s policy or certificate, except that the superintendent shall not conduct a review under this section unless the insured has exhausted the insurer’s internal review process. The insurer and the insured or authorized person shall provide the superintendent with any information required by the superintendent that is in their possession and is germane to the review.
Unless the superintendent is not able to do so because making the determination requires resolution of a medical issue, the superintendent shall determine whether the health care service at issue is a service covered under the terms of the insured’s policy or certificate. The superintendent shall notify the insured, or authorized person, and the insurer of its determination or that it is not able to make a determination because the determination requires the resolution of a medical issue.
If the superintendent notifies the insurer that making the determination requires the resolution of a medical issue, the insurer shall initiate an external review under section 3923.67 or 3923.68 of the Revised Code. If the superintendent notifies the insurer that the health care service is not a covered service, the insurer is not required to cover the service or afford the insured an external review.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
