1751.84 External review.
1751.84 External review.
(A) Except as provided in divisions (B) and (C) of this section, a health insuring corporation shall afford an enrollee an opportunity for an external review if both of the following are the case:
(1) The health insuring corporation has denied, reduced, or terminated coverage for what would be a covered health care service except for the fact that the health insuring corporation has determined that the health care service is not medically necessary;
(2) Except in the case of an expedited review, the service, plus any ancillary services and follow-up care, will cost the enrollee more than five hundred dollars if the proposed service is not covered by the health insuring corporation.
External review shall be conducted in accordance with this section, except that if an enrollee with a terminal condition meets all of the criteria of division (A) of section 1751.85 of the Revised Code, an external review shall be conducted under that section.
(B) An enrollee need not be afforded a review under this section in any of the following circumstances:
(1) The superintendent of insurance has determined under section 1751.831 of the Revised Code that the health care service is not a service covered under the terms of the enrollee’s policy, contract, or agreement.
(2) Except as provided in section 1751.811 of the Revised Code, the enrollee has failed to exhaust the health insuring corporation’s internal review process established pursuant to section 1751.83 of the Revised Code.
(3) The enrollee has previously been afforded an external review for the same adverse determination and no new clinical information has been submitted to the health insuring corporation.
(C)(1) A health insuring corporation may deny a request for an external review of an adverse determination if it is requested later than one hundred eighty days after the enrollee’s receipt of notice of the result of an internal review brought under section 1751.83 of the Revised Code. An external review may be requested by the enrollee, an authorized person, the enrollee’s provider, or a health care facility rendering health care service to the enrollee. The enrollee 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 enrollee.
(2) An external review must be requested in writing, except that if the enrollee 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 shall be submitted to the health insuring corporation not later than five days after the oral or written request is submitted.
Except in the case of an expedited review, a request for an external review must be accompanied by written certification from the enrollee’s provider or the health care facility rendering the health care service to the enrollee that the proposed service, plus any ancillary services and follow-up care , will cost the enrollee more than five hundred dollars if the proposed service is not covered by the health insuring corporation.
(3) For an expedited review, the enrollee’s provider must certify that the enrollee’s condition could, in the absence of immediate medical attention, result in any of the following:
(a) Placing the health of the enrollee or, with respect to a pregnant woman, the health of the enrollee 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 of an adverse determination 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 division (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 health insuring corporation or any officer, director, or managerial employee of the health insuring corporation;
(b) The enrollee, the enrollee’s provider, or the practice group of the enrollee’s provider;
(c) The health care facility at which the health care service requested by the enrollee would be provided;
(d) The development or manufacture of the principal drug, device, procedure, or therapy proposed for the enrollee.
(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 enrollees of the health insuring corporation.
(b) The clinical peer has staff privileges at a health care facility that provides health care services to enrollees of the health insuring corporation.
(c) The clinical peer is a participating provider but was not involved with the health insuring corporation’s adverse determination.
(4) Division (D)(2) of this section does not prohibit the health insuring corporation from paying the independent review organization for the conduct of the review.
(5) An enrollee 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 health insuring corporation.
(6)(a) The health insuring corporation shall provide to the independent review organization conducting the review a copy of those records in its possession that are relevant to the enrollee’s medical condition and the review. The records shall be used solely for the purpose of this division.
At the request of the independent review organization, the health insuring corporation, enrollee, or the provider or health care facility rendering health care services to the enrollee 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 enrollee and health insuring corporation. If a request is submitted orally or by electronic means to an enrollee or health insuring corporation, 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 enrollee and the health insuring corporation 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 health insuring corporation may elect to cover the service requested and terminate the review. The health insuring corporation shall notify the enrollee and all other parties involved with the decision by mail or, with the consent or approval of the enrollee, 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 health insuring corporation, the enrollee, the enrollee’s provider, and the health care facility rendering the health care service, including the following:
(i) The enrollee’s medical records;
(ii) The standards, criteria, and clinical rationale used by the health insuring corporation 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 health insuring corporation and the enrollee. If the enrollee’s provider or the health care facility rendering health care services to the enrollee requested the review, the independent review organization shall also send a copy of its decision to the enrollee’s provider or the health care facility.
(b) The independent review organization’s decision shall include a description of the enrollee’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 health insuring corporation 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 enrollee’s contract. The decision shall apply only to the individual enrollee’s external review.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
Effective Date: 05-01-2000