Ohio § 1753.14

§ 1753.14.

(A) A health insuring corporation that does not allow direct access to all specialists

shall establish and implement a procedure by which an enrollee may receive a standing

referral to a specialist.  The procedure shall provide for a standing referral to a specialist if a primary

care provider determines in consultation with a specialist that an enrollee needs

continuing care from a specialist.  The referral shall be made pursuant to a treatment plan approved by the health insuring

corporation in consultation with the primary care provider, a specialist, and the

enrollee.  The treatment plan may limit the number of visits to the specialist, limit the period

of time that the visits are authorized, or require that the specialist provide the

primary care provider with regular reports on the health care provided to the enrollee. (B) A health insuring corporation shall establish and implement a procedure by which

an enrollee with a condition or disease that requires specialized medical care over

a prolonged period of time and is life-threatening, degenerative, or disabling may

receive a referral to a specialist who has expertise in treating the condition or

disease for the purpose of having the specialist coordinate the enrollee's health

care.  The procedure shall provide for such a referral if a primary care provider determines

in consultation with the specialist that the enrollee needs the specialist's expertise.  The referral shall be made pursuant to a treatment plan approved by the health insuring

corporation in consultation with the primary care provider, the specialist, and the

enrollee.  After the referral is made, the specialist is authorized to provide health care

services to the enrollee in the same manner as the enrollee's primary care provider,

subject to the terms of the treatment plan. (C) The determinations described in divisions (A) and (B) of this section shall be made

within three business days after a request for the determination is made by the enrollee

or the enrollee's primary care provider and all appropriate medical records and other

items of information necessary to make the determination have been provided. (D) Once a determination in favor of a referral is made, the referral shall be made within

four business days after the determination.  This time period does not apply to standing referrals involving a rare or unusual

condition for which appropriate specialists are limited in number or otherwise difficult

to identify. Divisions (A) and (B) of this section do not require a health insuring corporation

to permit an enrollee to elect referral to a specialist who is not employed by or

under contract with the health insuring corporation for the provision of health care

services to the health insuring corporation's enrollees.