3923.76 Request for external review of coverage denial - public employee benefit plan.
(A) Except as provided in divisions (B) and (C) of this section, a public employee benefit plan shall afford a plan member an opportunity for an external review of a coverage denial when requested by the plan member or authorized person, if both of the following are the case:
(1) The plan has denied, reduced, or terminated coverage for what would be a covered health care service except that the plan has determined that the health care service is not medically necessary.
(2) Except in the case of expedited review, the proposed service, plus any ancillary services and follow-up care, will cost the plan member more than five hundred dollars if the proposed service is not covered by the plan.
External review shall be conducted in accordance with this section, except that if a plan member with a terminal condition meets all of the criteria of division (A) of section 3923.77 of the Revised Code, an external review shall be conducted under that section.
(B) A plan member need not be afforded a review under this section in any of the following circumstances:
(1) The superintendent of insurance has determined under section 3923.75 of the Revised Code that the health care service is not a service covered under the terms of the plan.
(2) The plan member has failed to exhaust the plan’s internal review process.
(3) The plan member has previously been afforded an external review for the same denial of coverage, and no new clinical information has been submitted to the plan.
(C)(1) A plan may deny a request from a plan member for an external review of an adverse decision from the plan’s internal appeal process if it is requested later than one hundred eighty days after receipt by the plan member of notice from the plan of the adverse decision. An external review may be requested by the plan member, an authorized person, the plan member’s provider, or a health care facility rendering health care service to the plan member. The plan member may request a review without the approval of the provider or the health care facility rendering the health care service. The provider or health care facility may not request a review without the prior consent of the plan member.
(2) An external review must be requested in writing, except that if the plan member has a condition that requires expedited review, the review may be requested orally or by electronic means. When an oral or electronic request for review is made, written confirmation of the request must be submitted to the plan not later than five days after the request is made.
Except in the case of an expedited review, a request for an external review must be accompanied by written certification from the plan member’s provider or the health care facility rendering the health care service to the plan member that the proposed service, plus any ancillary services and follow-up care, will cost the plan member more than five hundred dollars if the proposed service is not covered by the plan.
(3) For an expedited review, the plan member’s provider must certify that the plan member’s condition could, in the absence of immediate medical attention, result in any of the following:
(a) Placing the health of the plan member or, with respect to a pregnant woman, the health of the plan member or the unborn child, in serious jeopardy;
(b) Serious impairment to bodily functions;
(c) Serious dysfunction of any bodily organ or part.
(D) The procedures used in conducting an external review shall include all of the following:
(1) The review shall be conducted by an independent review organization assigned by the superintendent of insurance under section 3901.80 of the Revised Code.
(2) Except as provided in divisions (D)(3) and (4) of this section, neither the clinical peer nor any health care facility with which the clinical peer is affiliated shall have any professional, familial, or financial affiliation with any of the following:
(a) The plan or any officer, director, or managerial employee of the plan;
(b) The plan member, the plan member’s provider, or the practice group of the plan member’s provider;
(c) The health care facility at which the health care service requested by the plan member would be provided;
(d) The development or manufacture of the principal drug, device, procedure, or therapy proposed for the plan member.
(3) Division (D)(2) of this section does not prohibit a clinical peer from conducting a review under any of the following circumstances:
(a) The clinical peer is affiliated with an academic medical center that provides health care services to members of the plan.
(b) The clinical peer has staff privileges at a health care facility that provides health care services to members of the plan.
(c) The clinical peer has a contractual relationship with the plan but was not involved with the plan’s coverage decision.
(4) Division (D)(2) of this section does not prohibit the plan from paying the independent review organization for the conduct of the review.
(5) A plan member shall not be required to pay for any part of the cost of the review. The cost of the review shall be borne by the plan.
(6)(a) The plan shall provide to the independent review organization conducting the review a copy of those records in its possession that are relevant to the plan member’s medical condition and the review.
Records shall be used solely for the purpose of this division. At the request of the independent review organization, the plan, plan member, provider, or health care facility rendering health care services to the plan member shall provide any additional information the independent review organization requests to complete the review. A request for additional information may be made in writing, orally, or by electronic means. The independent review organization shall submit the request to the plan member and the plan. If a request is submitted orally or by electronic means to a plan member or plan, not later than five days after the request is submitted, the independent review organization shall provide written confirmation of the request. If the review was initiated by a provider or health care facility, a copy of the request shall be submitted to the provider or health care facility.
(b) An independent review organization is not required to make a decision if it has not received any requested information that it considers necessary to complete a review. An independent review organization that does not make a decision for this reason shall notify the plan member and the plan that a decision is not being made. The notice may be made in writing, orally, or by electronic means. An oral or electronic notice shall be confirmed in writing not later than five days after the oral or electronic notice is made. If the review was initiated by a provider or health care facility, a copy of the notice shall be submitted to the provider or health care facility.
(7) The plan may elect to cover the service requested and terminate the review. The plan shall notify the plan member and all other parties involved with the decision by mail, or with the consent or approval of the plan member, by electronic means.
(8) In making its decision, an independent review organization conducting the review shall take into account all of the following:
(a) Information submitted by the plan, the plan member, the plan member’s provider, and the health care facility rendering the health care service, including the following:
(i) The plan member’s medical records;
(ii) The standards, criteria, and clinical rationale used by the plan to make its decision.
(b) Findings, studies, research, and other relevant documents of government agencies and nationally recognized organizations, including the national institutes of health or any board recognized by the national institutes of health, the national cancer institute, the national academy of sciences, the United States food and drug administration, the health care financing administration of the United States department of health and human services, and the agency for health care policy and research;
(c) Relevant findings in peer-reviewed medical or scientific literature, published opinions of nationally recognized medical experts, and clinical guidelines adopted by relevant national medical societies.
(9)(a) In the case of an expedited review, the independent review organization shall issue a written decision not later than seven days after the filing of the request for review. In all other cases, the independent review organization shall issue a written decision not later than thirty days after the filing of the request. The independent review organization shall send a copy of its decision to the plan and the plan member. If the plan member’s provider or the health care facility rendering health care services to the plan member requested the review, the independent review organization shall also send a copy of its decision to the plan member’s provider or the health care facility.
(b) The independent review organization’s decision shall include a description of the plan member’s condition and the principal reasons for the decision and an explanation of the clinical rationale for the decision.
(E) The independent review organization shall base its decision on the information submitted under division (D)(8) of this section. In making its decision, the independent review organization shall consider safety, efficacy, appropriateness, and cost-effectiveness.
(F) The plan shall provide any coverage determined by the independent review organization’s decision to be medically necessary, subject to the other terms, limitations, and conditions of the plan.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
3923.76 Request for external review of coverage denial - public employee benefit plan.
(A) Except as provided in divisions (B) and (C) of this section, a public employee benefit plan shall afford a plan member an opportunity for an external review of a coverage denial when requested by the plan member or authorized person, if both of the following are the case:
(1) The plan has denied, reduced, or terminated coverage for what would be a covered health care service except that the plan has determined that the health care service is not medically necessary.
(2) Except in the case of expedited review, the proposed service, plus any ancillary services and follow-up care, will cost the plan member more than five hundred dollars if the proposed service is not covered by the plan.
External review shall be conducted in accordance with this section, except that if a plan member with a terminal condition meets all of the criteria of division (A) of section 3923.77 of the Revised Code, an external review shall be conducted under that section.
(B) A plan member need not be afforded a review under this section in any of the following circumstances:
(1) The superintendent of insurance has determined under section 3923.75 of the Revised Code that the health care service is not a service covered under the terms of the plan.
(2) The plan member has failed to exhaust the plan’s internal review process.
(3) The plan member has previously been afforded an external review for the same denial of coverage, and no new clinical information has been submitted to the plan.
(C)(1) A plan may deny a request from a plan member for an external review of an adverse decision from the plan’s internal appeal process if it is requested later than one hundred eighty days after receipt by the plan member of notice from the plan of the adverse decision. An external review may be requested by the plan member, an authorized person, the plan member’s provider, or a health care facility rendering health care service to the plan member. The plan member may request a review without the approval of the provider or the health care facility rendering the health care service. The provider or health care facility may not request a review without the prior consent of the plan member.
(2) An external review must be requested in writing, except that if the plan member has a condition that requires expedited review, the review may be requested orally or by electronic means. When an oral or electronic request for review is made, written confirmation of the request must be submitted to the plan not later than five days after the request is made.
Except in the case of an expedited review, a request for an external review must be accompanied by written certification from the plan member’s provider or the health care facility rendering the health care service to the plan member that the proposed service, plus any ancillary services and follow-up care, will cost the plan member more than five hundred dollars if the proposed service is not covered by the plan.
(3) For an expedited review, the plan member’s provider must certify that the plan member’s condition could, in the absence of immediate medical attention, result in any of the following:
(a) Placing the health of the plan member or, with respect to a pregnant woman, the health of the plan member or the unborn child, in serious jeopardy;
(b) Serious impairment to bodily functions;
(c) Serious dysfunction of any bodily organ or part.
(D) The procedures used in conducting an external review shall include all of the following:
(1) The review shall be conducted by an independent review organization assigned by the superintendent of insurance under section 3901.80 of the Revised Code.
(2) Except as provided in divisions (D)(3) and (4) of this section, neither the clinical peer nor any health care facility with which the clinical peer is affiliated shall have any professional, familial, or financial affiliation with any of the following:
(a) The plan or any officer, director, or managerial employee of the plan;
(b) The plan member, the plan member’s provider, or the practice group of the plan member’s provider;
(c) The health care facility at which the health care service requested by the plan member would be provided;
(d) The development or manufacture of the principal drug, device, procedure, or therapy proposed for the plan member.
(3) Division (D)(2) of this section does not prohibit a clinical peer from conducting a review under any of the following circumstances:
(a) The clinical peer is affiliated with an academic medical center that provides health care services to members of the plan.
(b) The clinical peer has staff privileges at a health care facility that provides health care services to members of the plan.
(c) The clinical peer has a contractual relationship with the plan but was not involved with the plan’s coverage decision.
(4) Division (D)(2) of this section does not prohibit the plan from paying the independent review organization for the conduct of the review.
(5) A plan member shall not be required to pay for any part of the cost of the review. The cost of the review shall be borne by the plan.
(6)(a) The plan shall provide to the independent review organization conducting the review a copy of those records in its possession that are relevant to the plan member’s medical condition and the review.
Records shall be used solely for the purpose of this division. At the request of the independent review organization, the plan, plan member, provider, or health care facility rendering health care services to the plan member shall provide any additional information the independent review organization requests to complete the review. A request for additional information may be made in writing, orally, or by electronic means. The independent review organization shall submit the request to the plan member and the plan. If a request is submitted orally or by electronic means to a plan member or plan, not later than five days after the request is submitted, the independent review organization shall provide written confirmation of the request. If the review was initiated by a provider or health care facility, a copy of the request shall be submitted to the provider or health care facility.
(b) An independent review organization is not required to make a decision if it has not received any requested information that it considers necessary to complete a review. An independent review organization that does not make a decision for this reason shall notify the plan member and the plan that a decision is not being made. The notice may be made in writing, orally, or by electronic means. An oral or electronic notice shall be confirmed in writing not later than five days after the oral or electronic notice is made. If the review was initiated by a provider or health care facility, a copy of the notice shall be submitted to the provider or health care facility.
(7) The plan may elect to cover the service requested and terminate the review. The plan shall notify the plan member and all other parties involved with the decision by mail, or with the consent or approval of the plan member, by electronic means.
(8) In making its decision, an independent review organization conducting the review shall take into account all of the following:
(a) Information submitted by the plan, the plan member, the plan member’s provider, and the health care facility rendering the health care service, including the following:
(i) The plan member’s medical records;
(ii) The standards, criteria, and clinical rationale used by the plan to make its decision.
(b) Findings, studies, research, and other relevant documents of government agencies and nationally recognized organizations, including the national institutes of health or any board recognized by the national institutes of health, the national cancer institute, the national academy of sciences, the United States food and drug administration, the health care financing administration of the United States department of health and human services, and the agency for health care policy and research;
(c) Relevant findings in peer-reviewed medical or scientific literature, published opinions of nationally recognized medical experts, and clinical guidelines adopted by relevant national medical societies.
(9)(a) In the case of an expedited review, the independent review organization shall issue a written decision not later than seven days after the filing of the request for review. In all other cases, the independent review organization shall issue a written decision not later than thirty days after the filing of the request. The independent review organization shall send a copy of its decision to the plan and the plan member. If the plan member’s provider or the health care facility rendering health care services to the plan member requested the review, the independent review organization shall also send a copy of its decision to the plan member’s provider or the health care facility.
(b) The independent review organization’s decision shall include a description of the plan member’s condition and the principal reasons for the decision and an explanation of the clinical rationale for the decision.
(E) The independent review organization shall base its decision on the information submitted under division (D)(8) of this section. In making its decision, the independent review organization shall consider safety, efficacy, appropriateness, and cost-effectiveness.
(F) The plan shall provide any coverage determined by the independent review organization’s decision to be medically necessary, subject to the other terms, limitations, and conditions of the plan.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
3923.76 Request for external review of coverage denial - public employee benefit plan.
(A) Except as provided in divisions (B) and (C) of this section, a public employee benefit plan shall afford a plan member an opportunity for an external review of a coverage denial when requested by the plan member or authorized person, if both of the following are the case:
(1) The plan has denied, reduced, or terminated coverage for what would be a covered health care service except that the plan has determined that the health care service is not medically necessary.
(2) Except in the case of expedited review, the proposed service, plus any ancillary services and follow-up care, will cost the plan member more than five hundred dollars if the proposed service is not covered by the plan.
External review shall be conducted in accordance with this section, except that if a plan member with a terminal condition meets all of the criteria of division (A) of section 3923.77 of the Revised Code, an external review shall be conducted under that section.
(B) A plan member need not be afforded a review under this section in any of the following circumstances:
(1) The superintendent of insurance has determined under section 3923.75 of the Revised Code that the health care service is not a service covered under the terms of the plan.
(2) The plan member has failed to exhaust the plan’s internal review process.
(3) The plan member has previously been afforded an external review for the same denial of coverage, and no new clinical information has been submitted to the plan.
(C)(1) A plan may deny a request from a plan member for an external review of an adverse decision from the plan’s internal appeal process if it is requested later than one hundred eighty days after receipt by the plan member of notice from the plan of the adverse decision. An external review may be requested by the plan member, an authorized person, the plan member’s provider, or a health care facility rendering health care service to the plan member. The plan member may request a review without the approval of the provider or the health care facility rendering the health care service. The provider or health care facility may not request a review without the prior consent of the plan member.
(2) An external review must be requested in writing, except that if the plan member has a condition that requires expedited review, the review may be requested orally or by electronic means. When an oral or electronic request for review is made, written confirmation of the request must be submitted to the plan not later than five days after the request is made.
Except in the case of an expedited review, a request for an external review must be accompanied by written certification from the plan member’s provider or the health care facility rendering the health care service to the plan member that the proposed service, plus any ancillary services and follow-up care, will cost the plan member more than five hundred dollars if the proposed service is not covered by the plan.
(3) For an expedited review, the plan member’s provider must certify that the plan member’s condition could, in the absence of immediate medical attention, result in any of the following:
(a) Placing the health of the plan member or, with respect to a pregnant woman, the health of the plan member or the unborn child, in serious jeopardy;
(b) Serious impairment to bodily functions;
(c) Serious dysfunction of any bodily organ or part.
(D) The procedures used in conducting an external review shall include all of the following:
(1) The review shall be conducted by an independent review organization assigned by the superintendent of insurance under section 3901.80 of the Revised Code.
(2) Except as provided in divisions (D)(3) and (4) of this section, neither the clinical peer nor any health care facility with which the clinical peer is affiliated shall have any professional, familial, or financial affiliation with any of the following:
(a) The plan or any officer, director, or managerial employee of the plan;
(b) The plan member, the plan member’s provider, or the practice group of the plan member’s provider;
(c) The health care facility at which the health care service requested by the plan member would be provided;
(d) The development or manufacture of the principal drug, device, procedure, or therapy proposed for the plan member.
(3) Division (D)(2) of this section does not prohibit a clinical peer from conducting a review under any of the following circumstances:
(a) The clinical peer is affiliated with an academic medical center that provides health care services to members of the plan.
(b) The clinical peer has staff privileges at a health care facility that provides health care services to members of the plan.
(c) The clinical peer has a contractual relationship with the plan but was not involved with the plan’s coverage decision.
(4) Division (D)(2) of this section does not prohibit the plan from paying the independent review organization for the conduct of the review.
(5) A plan member shall not be required to pay for any part of the cost of the review. The cost of the review shall be borne by the plan.
(6)(a) The plan shall provide to the independent review organization conducting the review a copy of those records in its possession that are relevant to the plan member’s medical condition and the review.
Records shall be used solely for the purpose of this division. At the request of the independent review organization, the plan, plan member, provider, or health care facility rendering health care services to the plan member shall provide any additional information the independent review organization requests to complete the review. A request for additional information may be made in writing, orally, or by electronic means. The independent review organization shall submit the request to the plan member and the plan. If a request is submitted orally or by electronic means to a plan member or plan, not later than five days after the request is submitted, the independent review organization shall provide written confirmation of the request. If the review was initiated by a provider or health care facility, a copy of the request shall be submitted to the provider or health care facility.
(b) An independent review organization is not required to make a decision if it has not received any requested information that it considers necessary to complete a review. An independent review organization that does not make a decision for this reason shall notify the plan member and the plan that a decision is not being made. The notice may be made in writing, orally, or by electronic means. An oral or electronic notice shall be confirmed in writing not later than five days after the oral or electronic notice is made. If the review was initiated by a provider or health care facility, a copy of the notice shall be submitted to the provider or health care facility.
(7) The plan may elect to cover the service requested and terminate the review. The plan shall notify the plan member and all other parties involved with the decision by mail, or with the consent or approval of the plan member, by electronic means.
(8) In making its decision, an independent review organization conducting the review shall take into account all of the following:
(a) Information submitted by the plan, the plan member, the plan member’s provider, and the health care facility rendering the health care service, including the following:
(i) The plan member’s medical records;
(ii) The standards, criteria, and clinical rationale used by the plan to make its decision.
(b) Findings, studies, research, and other relevant documents of government agencies and nationally recognized organizations, including the national institutes of health or any board recognized by the national institutes of health, the national cancer institute, the national academy of sciences, the United States food and drug administration, the health care financing administration of the United States department of health and human services, and the agency for health care policy and research;
(c) Relevant findings in peer-reviewed medical or scientific literature, published opinions of nationally recognized medical experts, and clinical guidelines adopted by relevant national medical societies.
(9)(a) In the case of an expedited review, the independent review organization shall issue a written decision not later than seven days after the filing of the request for review. In all other cases, the independent review organization shall issue a written decision not later than thirty days after the filing of the request. The independent review organization shall send a copy of its decision to the plan and the plan member. If the plan member’s provider or the health care facility rendering health care services to the plan member requested the review, the independent review organization shall also send a copy of its decision to the plan member’s provider or the health care facility.
(b) The independent review organization’s decision shall include a description of the plan member’s condition and the principal reasons for the decision and an explanation of the clinical rationale for the decision.
(E) The independent review organization shall base its decision on the information submitted under division (D)(8) of this section. In making its decision, the independent review organization shall consider safety, efficacy, appropriateness, and cost-effectiveness.
(F) The plan shall provide any coverage determined by the independent review organization’s decision to be medically necessary, subject to the other terms, limitations, and conditions of the plan.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
