Ohio § 3922.09

§ 3922.09.

(A) A covered person may make a request for an expedited external review, except as provided

in division (I) of this section: (1) After an adverse benefit determination, if both of the following apply: (a) The covered person's treating physician certifies that the adverse benefit determination

involves a medical condition that could seriously jeopardize the life or health of

the covered person, or would jeopardize the covered person's ability to regain maximum

function, if treated after the time frame of an expedited internal appeal; (b) The covered person has filed a request for an expedited internal appeal. (2) After a final adverse benefit determination, if either of the following apply: (a) The covered person's treating physician certifies that the adverse benefit determination

involves a medical condition that could seriously jeopardize the life or health of

the covered person, or would jeopardize the covered person's ability to regain maximum

function, if treated after the time frame of a standard external review; (b) The final adverse benefit determination concerns an admission, availability of care,

continued stay, or health care service for which the covered person received emergency

services, but has not yet been discharged from a facility. (B) Immediately upon receipt of a request for an expedited external review, the health

plan issuer shall determine if the request is complete under any associated rules,

policies, or procedures adopted by the superintendent of insurance and eligible for

expedited external review under division (A) of this section.  The health plan issuer shall immediately notify the covered person of its determination

in accordance with any associated rules, policies, or procedures adopted by the superintendent

of insurance. (C) If a request for an expedited review is complete and eligible, the health plan issuer

shall immediately provide or transmit all necessary documents and information considered

in making the adverse benefit determination in question to the assigned independent

review organization electronically, or by facsimile or other available expeditious

method. (D) In addition to the information transmitted under division (C) of this section, the

assigned independent review organization shall also consider relevant information

as required under section 3922.07 of the Revised Code . (E) As expeditiously as the covered person's medical condition requires, but no more

than seventy-two hours after receipt by the health plan issuer of a request for an

expedited, external review, the assigned independent review organization shall uphold

or reverse the adverse benefit determination. (F) If a health plan issuer fails to provide the documents and information as required

in division (C) of this section, the independent review organization shall not delay

the external review and may accordingly reverse the adverse benefit determination. (G) An independent review organization shall promptly notify the covered person, health

plan issuer, and superintendent of insurance of any decision made under this section.  If such a notice is not made in writing, the independent review organization, shall

provide, within forty-eight hours of making the decision, written confirmation, including

the information required under division (H)(3) of section 3922.05 of the Revised Code , of its decision to the covered person, the health plan issuer, and the superintendent

of insurance. (H) Upon receipt of a notice by an independent review organization to reverse the adverse

benefit determination, a health plan issuer shall immediately provide coverage for

the health care service or services in question. (I) An expedited, external review may not be provided for retrospective final adverse

benefit determinations.