Ohio § 3922.14

§ 3922.14.

(A) To be accredited by the superintendent of insurance to conduct external reviews under section 3922.13 of the Revised Code , in addition to the requirements provided in section 3922.13 of the Revised Code and any associated rules adopted by the superintendent, an independent review organization

shall do all of the following: (1) Develop and maintain written policies and procedures that govern all aspects of both

the standard external review process and the expedited external review process set

forth in this chapter, including a quality assurance mechanism that does all of the

following: (a) Ensures that external reviews are conducted within the time frames prescribed under

this chapter and that the required notices are provided in a timely manner; (b) Ensures the selection of qualified and impartial clinical reviewers to conduct external

reviews on behalf of the independent review organization; (c) Ensures that chosen clinical reviewers are suitably matched according to their area

of expertise to specific cases and that the independent review organization employs

or contracts with an adequate number of clinical reviewers to meet this requirement; (d) Ensures the confidentiality of medical and treatment records and clinical review

criteria; (e) Ensures that any person employed by, or who is under contract with, the independent

review organization adheres to the requirements of this chapter. (2) Maintain a toll-free telephone service to receive information on a twenty-four-hour-a-day,

seven-days-a-week basis related to external reviews that is capable of accepting,

recording, and providing appropriate instruction to incoming telephone callers during

other than normal business hours; (3) Agree to maintain and provide to the superintendent, upon request and in accordance

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

insurance, the information prescribed in section 3922.17 of the Revised Code . (B) An independent review organization may not own or control, be a subsidiary of or

in any way be owned or controlled by, or exercise control with a health plan issuer,

a national, state, or local trade association of health plan issuers, or a national,

state, or local trade association of health care providers. (C)(1) Neither the independent review organization selected to conduct the external review

nor any clinical reviewer assigned by the independent organization to conduct the

external review may have a material, professional, familial, or financial affiliation

with any of the following: (a) The health plan issuer that is the subject of the external review, or any officer,

director, or management employee of the health plan issuer; (b) The covered person whose treatment is the subject of the external review; (c) The health care provider, or the health care provider's medical group or independent

practice association, recommending the health care service or treatment that is the

subject of the external review; (d) The facility at which the recommended health care service would be provided; (e) The developer or manufacturer of the principal drug, device, procedure, or other

therapy being recommended for the covered person whose treatment is the subject of

the external review. (2) The superintendent may make a determination as to whether an independent review organization

or a clinical reviewer of the independent review organization has a material professional,

familial, or financial conflict of interest for purposes of division (C)(1) of this

section.  In making this determination, the superintendent may take into consideration situations

where an independent review organization, or a clinical reviewer, may have an apparent

conflict of interest, but that the characteristics of the relationship or connection

in question are such that they do not fall under the definition of conflict of interest

provided under division (D)(1) of this section.  If the superintendent determines that a conflict of interest exists, the superintendent

shall disallow an independent review organization or a clinical reviewer from conducting

the external review in question.  Such determinations related to conflicts of interest are the sole discretion of

the superintendent of insurance. (D)(1) An independent review organization that is accredited by a nationally recognized

private accrediting entity that has independent review accreditation standards that

the superintendent has determined are equivalent to or exceed the minimum qualifications

of this section shall be presumed in compliance with this section to be eligible for

accreditation by the superintendent under section 3922.13 of the Revised Code . (2) The superintendent shall initially review and periodically review the independent

review organization accreditation standards of a nationally recognized private accrediting

entity to determine whether the entity's standards are, and continue to be, equivalent

to or exceed the minimum qualifications established under this section.  The superintendent may accept a review conducted by the national association of

insurance commissioners for the purpose of the determination under this division. (3) Upon request, a nationally recognized, private accrediting entity shall make its

current independent review organization accreditation standards available to the superintendent

or the national association of insurance commissioners in order for the superintendent

to determine if the entity's standards are equivalent to or exceed the minimum qualifications

established under this section.  The superintendent may exclude any private accrediting entity that is not reviewed

by the national association of insurance commissioners. (E) An independent review organization shall be unbiased in its review of adverse benefit

determinations and shall establish and maintain written procedures to ensure that

it is unbiased.