3923.75 Review of denials of health care coverage - public employee benefit plan.
(A) As used in sections 3923.75 to 3923.79 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 a plan member with respect to health care decisions.
(B) Sections 3923.75 to 3923.79 of the Revised Code do not apply to any public employee benefit plan 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 plan members 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 public employee benefit plan.
On receipt of a written request from a plan member or authorized person, the superintendent shall consider whether the health care service is a service covered under the terms of the plan, except that the superintendent shall not conduct a review under this section unless the plan member has exhausted the plan’s internal review process. The plan and the plan member 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 plan. The superintendent shall notify the plan member, or authorized person, and the plan 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 plan that making the determination requires the resolution of a medical issue, the plan shall initiate an external review under section 3923.76 or 3923.77 of the Revised Code. If the superintendent notifies the plan that the health care service is not a covered service, the plan is not required to cover the service or afford the plan member an external review.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
3923.75 Review of denials of health care coverage - public employee benefit plan.
(A) As used in sections 3923.75 to 3923.79 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 a plan member with respect to health care decisions.
(B) Sections 3923.75 to 3923.79 of the Revised Code do not apply to any public employee benefit plan 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 plan members 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 public employee benefit plan.
On receipt of a written request from a plan member or authorized person, the superintendent shall consider whether the health care service is a service covered under the terms of the plan, except that the superintendent shall not conduct a review under this section unless the plan member has exhausted the plan’s internal review process. The plan and the plan member 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 plan. The superintendent shall notify the plan member, or authorized person, and the plan 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 plan that making the determination requires the resolution of a medical issue, the plan shall initiate an external review under section 3923.76 or 3923.77 of the Revised Code. If the superintendent notifies the plan that the health care service is not a covered service, the plan is not required to cover the service or afford the plan member an external review.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
3923.75 Review of denials of health care coverage - public employee benefit plan.
(A) As used in sections 3923.75 to 3923.79 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 a plan member with respect to health care decisions.
(B) Sections 3923.75 to 3923.79 of the Revised Code do not apply to any public employee benefit plan 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 plan members 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 public employee benefit plan.
On receipt of a written request from a plan member or authorized person, the superintendent shall consider whether the health care service is a service covered under the terms of the plan, except that the superintendent shall not conduct a review under this section unless the plan member has exhausted the plan’s internal review process. The plan and the plan member 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 plan. The superintendent shall notify the plan member, or authorized person, and the plan 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 plan that making the determination requires the resolution of a medical issue, the plan shall initiate an external review under section 3923.76 or 3923.77 of the Revised Code. If the superintendent notifies the plan that the health care service is not a covered service, the plan is not required to cover the service or afford the plan member an external review.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
