Ohio § 3922.04

§ 3922.04.

(A) Except as provided in division (E) of this section, a health plan issuer is not required

to grant a request for a standard external review made under section 3922.08 or 3922.10 of the Revised Code until the covered person has exhausted the health plan issuer's internal appeal process. (B) An internal appeal process shall be considered exhausted if a covered person has

requested an internal appeal and has not received a written decision from the health

plan issuer within the time frame required by 29 C.F.R. 2560.503-1 or the health plan issuer fails to adhere to all requirements of the internal appeals

process. (C) Notwithstanding division (B) of this section, the internal appeals process will not

be deemed exhausted based on de minimis violations that do not cause, and are not

likely to cause, prejudice or harm to the covered person so long as the health plan

issuer demonstrates that the violation was for good cause or due to matters beyond

the control of the health plan issuer and that the violation occurred in the context

of an ongoing, good faith exchange of information between the health plan issuer and

the covered person, and is not reflective of a pattern or practice of noncompliance,

except that: (1) If the health plan issuer denies a request for external review under this division,

the covered person may request written explanation from the health plan issuer, and

the health plan issuer shall provide the explanation within ten days, including a

specific description of its basis, if any, for asserting that the delay should not

cause the internal appeals process to be considered exhausted; (2) The covered person may request review by the superintendent of the health plan issuer's

explanation provided under division (C)(1) of this section and if the superintendent

affirms the health plan issuer's explanation, the covered person may, within ten days

of the superintendent's notice of decision, resubmit and pursue the internal appeal

process.  Time periods for refiling the internal appeal shall begin to run upon receipt of

such notice by the covered person. (D) Notwithstanding division (B) of this section, a covered person shall not make a request

for an external review of an adverse benefit determination involving a retrospective

review determination made pursuant to a utilization review until the covered person

has exhausted the health plan issuer's internal appeals process. (E) A request for an external review of an adverse benefit determination may be made

before the covered person has exhausted the health plan issuer's internal appeals

procedures whenever the health plan issuer agrees to waive the exhaustion requirement.  If the internal appeal process is waived, the covered person may file a request

in writing for a standard external review under section 3922.08 or 3922.10 of the Revised Code . (F) Notwithstanding any other section in this chapter, health plan issuers offering individual

health insurance coverage, including coverage offered to individuals through nonemployer

groups shall not require more than one level of internal appeal before the individual

may request an external review.