Ohio § 3901.381

§ 3901.381.

(A) Except as provided in sections 3901.382 , 3901.383 , 3901.384 , and 3901.386 of the Revised Code , a third-party payer shall process a claim for payment for health care services rendered

by a provider to a beneficiary in accordance with this section. (B)(1) Unless division (B)(2) or (3) of this section applies, when a third-party payer receives

from a provider or beneficiary a claim on the standard claim form prescribed in rules

adopted by the superintendent of insurance under section 3902.22 of the Revised Code , the third-party payer shall pay or deny the claim not later than thirty days after

receipt of the claim.  When a third-party payer denies a claim, the third-party payer shall notify the

provider and the beneficiary.  The notice shall state, with specificity, why the third-party payer denied the claim. (2)(a) Unless division (B)(3) of this section applies, when a provider or beneficiary has

used the standard claim form, but the third-party payer determines that reasonable

supporting documentation is needed to establish the third-party payer's responsibility

to make payment, the third-party payer shall pay or deny the claim not later than

forty-five days after receipt of the claim.  Supporting documentation includes the verification of employer and beneficiary coverage

under a benefits contract, confirmation of premium payment, medical information regarding

the beneficiary and the services provided, information on the responsibility of another

third-party payer to make payment or confirmation of the amount of payment by another

third-party payer, and information that is needed to correct material deficiencies

in the claim related to a diagnosis or treatment or the provider's identification. Not later than thirty days after receipt of the claim, the third-party payer shall

notify all relevant external sources that the supporting documentation is needed.  All such notices shall state, with specificity, the supporting documentation needed.  If the notice was not provided in writing, the provider, beneficiary, or third-party

payer may request the third-party payer to provide the notice in writing, and the

third-party payer shall then provide the notice in writing.  If any of the supporting documentation is under the control of the beneficiary,

the beneficiary shall provide the supporting documentation to the third-party payer. The number of days that elapse between the third-party payer's last request for supporting

documentation within the thirty-day period and the third-party payer's receipt of

all of the supporting documentation that was requested shall not be counted for purposes

of determining the third-party payer's compliance with the time period of not more

than forty-five days for payment or denial of a claim.  Except as provided in division (B)(2)(b) of this section, if the third-party payer

requests additional supporting documentation after receiving the initially requested

documentation, the number of days that elapse between making the request and receiving

the additional supporting documentation shall be counted for purposes of determining

the third-party payer's compliance with the time period of not more than forty-five

days. (b) If a third-party payer determines, after receiving initially requested documentation,

that it needs additional supporting documentation pertaining to a beneficiary's preexisting

condition, which condition was unknown to the third-party payer and about which it

was reasonable for the third-party payer to have no knowledge at the time of its initial

request for documentation, and the third-party payer subsequently requests this additional

supporting documentation, the number of days that elapse between making the request

and receiving the additional supporting documentation shall not be counted for purposes

of determining the third-party payer's compliance with the time period of not more

than forty-five days. (c) When a third-party payer denies a claim, the third-party payer shall notify the provider

and the beneficiary.  The notice shall state, with specificity, why the third-party payer denied the claim. (d) If a third-party payer determines that supporting documentation related to medical

information is routinely necessary to process a claim for payment of a particular

health care service, the third-party payer shall establish a description of the supporting

documentation that is routinely necessary and make the description available to providers

in a readily accessible format. Third-party payers and providers shall, in connection with a claim, use the most current

CPT code in effect, as published by the American medical association, the most current

ICD-10 code in effect, as published by the United States department of health and

human services, the most current CDT code in effect, as published by the American

dental association, or the most current HCPCS code in effect, as published by the

United States centers for medicare and medicaid services. (3) When a provider or beneficiary submits a claim by using the standard claim form prescribed

in the superintendent's rules, but the information provided in the claim is materially

deficient, the third-party payer shall notify the provider or beneficiary not later

than fifteen days after receipt of the claim.  The notice shall state, with specificity, the information needed to correct all

material deficiencies.  Once the material deficiencies are corrected, the third-party payer shall proceed

in accordance with division (B)(1) or (2) of this section. It is not a violation of the notification time period of not more than fifteen days

if a third-party payer fails to notify a provider or beneficiary of material deficiencies

in the claim related to a diagnosis or treatment or the provider's identification.  A third-party payer may request the information necessary to correct these deficiencies

after the end of the notification time period.  Requests for such information shall be made as requests for supporting documentation

under division (B)(2) of this section, and payment or denial of the claim is subject

to the time periods specified in that division. (C) For purposes of this section, if a dispute exists between a provider and a third-party

payer as to the day a claim form was received by the third-party payer, both of the

following apply: (1) If the provider or a person acting on behalf of the provider submits a claim directly

to a third-party payer by mail and retains a record of the day the claim was mailed,

there exists a rebuttable presumption that the claim was received by the third-party

payer on the fifth business day after the day the claim was mailed, unless it can

be proven otherwise. (2) If the provider or a person acting on behalf of the provider submits a claim directly

to a third-party payer electronically, there exists a rebuttable presumption that

the claim was received by the third-party payer twenty-four hours after the claim

was submitted, unless it can be proven otherwise. (D) Nothing in this section requires a third-party payer to provide more than one notice

to an employer whose premium for coverage of employees under a benefits contract has

not been received by the third-party payer. (E) Compliance with the provisions of division (B)(3) of this section shall be determined

separately from compliance with the provisions of divisions (B)(1) and (2) of this

section. (F) A third-party payer shall transmit electronically any payment with respect to claims

that the third-party payer receives electronically and pays to a contracted provider

under this section and under sections 3901.383 , 3901.384 , and 3901.386 of the Revised Code .  A provider shall not refuse to accept a payment made under this section or sections 3901.383 , 3901.384 , and 3901.386 of the Revised Code on the basis that the payment was transmitted electronically.