Ohio § 3922.11

§ 3922.11.

(A) The superintendent of insurance shall establish and maintain a system for receiving

and reviewing requests for external review for adverse benefit determinations where

the determination by the health plan issuer was based on a contractual issue and did

not involve a medical judgment or a determination based on any medical information,

except for emergency services, as specified in division (C) of section 3922.05 of the Revised Code . (B) A health plan issuer shall submit a request for external review pursuant to division (B) or (C) of section 3922.05 of the Revised Code to the superintendent, in accordance with any associated rules, policies, or procedures

adopted by the superintendent of insurance. (C) On receipt of a request from a health plan issuer, the superintendent shall consider

whether the health care service is a service covered under the terms of the covered

person's policy, contract, certificate, or agreement, except that the superintendent

shall not conduct a review under this section unless the covered person has exhausted

the health plan issuer's internal appeal process, pursuant to sections 3922.03 and 3922.04 of the Revised Code .  The health plan issuer and covered person shall provide the superintendent with

any information required by the superintendent that is in their possession and is

germane to the review. (D) Unless the superintendent is not able to do so because making the determination requires

a medical judgment or a determination based on medical information, the superintendent

shall determine whether the health care service at issue is a service covered under

the terms of the covered person's contract, policy, certificate, or agreement.  The superintendent shall notify the covered person and the health plan issuer of

the superintendent's determination. (E) If the superintendent notifies the health plan issuer that making the determination

requires a medical judgment or a determination based on medical information, the health

plan issuer shall initiate an external review under this chapter. (F) If the superintendent determines that the health service is a covered service, the

health plan issuer shall cover the service. (G) If the superintendent determines that the health care service is not a covered service,

the health plan issuer is not required to cover the service or afford the covered

person an external review by an independent review organization.