1751.831 System for receiving and reviewing requests for review.
1751.831 System for receiving and reviewing requests for review.
The superintendent of insurance shall establish and maintain a system for receiving and reviewing requests for review from or on behalf of enrollees who, under section 1751.83 of the Revised Code, have been denied coverage of a health care service or had coverage reduced or terminated when the grounds for the denial, reduction, or termination is that the service is not a service covered under the terms of the enrollee’s policy, contract, or agreement.
On receipt of a written request from an enrollee or authorized person, the superintendent shall consider whether the health care service is a service covered under the terms of the enrollee’s policy, contract, or agreement, except that the superintendent shall not conduct a review under this section unless the enrollee has exhausted the health insuring corporation’s internal review process established pursuant to section 1751.83 of the Revised Code. The health insuring corporation and the enrollee 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 enrollee’s contract, policy, or agreement. The superintendent shall notify the enrollee, or authorized person, and the health insuring corporation of the superintendent’s determination or that the superintendent is not able to make a determination.
If the superintendent notifies the health insuring corporation that making the determination requires the resolution of a medical issue, the health insuring corporation shall initiate an external review under section 1751.84 or 1751.85 of the Revised Code. If the superintendent notifies the health insuring corporation that the health service is a covered service, the health insuring corporation shall cover the service . If the superintendent notifies the health insuring corporation that the health care service is not a covered service, the health insuring corporation is not required to cover the service or afford the enrollee an external review.
Amended by 128th General Assembly File No. 9, HB 1, § 101.01, eff. 10/16/2009.
Effective Date: 05-01-2000