Bill Text: OH SB393 | 2011-2012 | 129th General Assembly | Introduced

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Bill Title: To create the Ohio Health Insurance Oversight Board and to require that external reviews of adverse determinations be conducted by a panel of three clinical peers appointed by the Board.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2012-12-11 - To Insurance, Commerce, & Labor [SB393 Detail]

Download: Ohio-2011-SB393-Introduced.html

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As Introduced

129th General Assembly Regular Session 2011-2012

S. B. No. 393

Senator Lehner 

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A BILL

To amend sections 1751.83, 3922.01, 3922.03, 3922.05,

1

3922.06, 3922.07, 3922.08, 3922.09, 3922.10,

2

3922.14, 3922.15, 3922.16, 3922.17, 3922.20, and

3

4731.36, to enact section 3901.85, and to repeal

4

section 3922.13 of the Revised Code to create the

5

Ohio Health Insurance Oversight Board and to

6

require that external reviews of adverse

7

determinations be conducted by a panel of three

8

clinical peers appointed by the Board.

9

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1.  That sections 1751.83, 3922.01, 3922.03, 3922.05,	10
3922.06, 3922.07, 3922.08, 3922.09, 3922.10, 3922.14, 3922.15,	11
3922.16, 3922.17, 3922.20, and 4731.36 be amended and section	12
3901.85 of the Revised Code be enacted to read as follows:	13

Sec. 1751.83.  A health insuring corporation shall establish	14
and maintain an internal review system that has been approved by	15
the superintendent of insurance. The system shall provide for	16
review by a clinical peer and include adequate and reasonable	17
procedures for review and resolution of appeals from enrollees	18
concerning adverse determinations made under section 1751.81 of	19
the Revised Code, including procedures for verifying and reviewing	20
appeals from enrollees whose medical conditions require expedited	21
review.	22

A health insuring corporation shall consider and provide a	23
written response to each request for an internal review not later	24
than thirtyfourteen days after receipt of the request, except	25
that if the seriousness of the enrollee's medical condition	26
requires an expedited review, the health insuring corporation	27
shall provide the written response not later than seven days after	28
receipt of the request or in accordance with applicable preemptive	29
federal laws or regulations. The response shall state the reason	30
for the health insuring corporation's decision, inform the	31
enrollee of the right to pursue a further review, and explain the	32
procedures for initiating the review, including the time frames	33
within which the enrollee must request the review, as specified in	34
section 3922.02 of the Revised Code. Failure by a health insuring	35
corporation to provide a written response within the time frames	36
specified under this section shall be deemed a denial by the	37
health insuring corporation for purposes of requesting an external	38
review under Chapter 3922. of the Revised Code.	39

If the health insuring corporation has denied, reduced, or	40
terminated coverage for a health care service on the grounds that	41
the service is not a service covered under the terms of the	42
enrollee's policy, contract, or agreement, the response shall	43
inform the enrollee of the right to request a review by the	44
superintendent of insurance under Chapter 3922. of the Revised	45
Code. If the health insuring corporation has denied, reduced, or	46
terminated coverage for a health care service on the grounds that	47
the service is not medically necessary, the response shall inform	48
the enrollee of the right to request an external review under	49
Chapter 3922. of the Revised Code.	50

The health insuring corporation shall make available to the	51
superintendent for inspection copies of all documents in the	52
health insuring corporation's possession related to reviews	53
conducted pursuant to this section, including medical records	54
related to those reviews, and of responses, for three years	55
following completion of the review.	56

Sec. 3901.85.  (A) There is hereby created within the	57
department of insurance the Ohio health insurance oversight board.	58
The board shall consist of the following members appointed by the	59
superintendent of insurance:	60

(1) Two consumer representatives;

61

(2) Two physicians representing insurers;

62

(3) One podiatrist;

63

(4) Eleven physicians, who hold a license issued by the state	64
medical board to practice medicine and surgery or osteopathic	65
medicine and surgery, composed as follows:	66

(a) One general surgeon;

67

(b) Two surgical physicians;

68

(c) One family-practice physician;

69

(d) One psychiatrist;

70

(e) Two nonsurgical physicians;

71

(f) One hospital administrator;

72

(g) One nurse;

73

(h) One psychologist;

74

(i) One chiropractor.

75

(B) The superintendent of insurance shall solicit	76
recommendations for each appointment required under division (A)	77
of this section from the respective trade association of each of	78
the medical fields represented on the board.	79

(C) The initial members of the board shall serve staggered	80
terms of one, two, or three years, as determined by the	81
superintendent. Thereafter, terms of office for all members shall	82
be three years, with each term ending on the same day of the same	83
month as the term it succeeds. Each member shall hold office from	84
the date of appointment until the end of the term for which the	85
member was appointed. Members may be reappointed.	86

Vacancies shall be filled in the same manner as original	87
appointments. Any member appointed to fill a vacancy occurring	88
prior to the expiration of the term for which the member's	89
predecessor was appointed shall hold office for the remainder of	90
that term. A member shall continue in office subsequent to the	91
expiration date of the member's term until the member's successor	92
takes office or until a period of sixty days has elapsed,	93
whichever occurs first.	94

(D) The board shall elect a chairperson from one of the	95
physician board members. The board shall meet at the call of the	96
chairperson. A majority of the members of the board constitutes a	97
quorum.	98

(E) Members of the board shall be reimbursed for all actual	99
necessary expenses incurred while serving on the board.	100

(F)(1) The board shall provide oversight for health insurance	101
policies and procedures to ensure that those policies and	102
procedures are reasonable and consistent with patient safety.	103

(2) If the board determines that a policy or procedure of an	104
insurer is not reasonable or consistent with patient safety or	105
that a definition of medical necessity utilized by an	106
administrator is not reasonable or consistent with patient safety,	107
the board shall issue the insurer or administrator a warning and	108
direct the insurer or administrator to remedy the policy,	109
procedure, or definition.	110

(3) If the insurer or administrator does not remedy the	111
policy, procedure, or definition that the board determined to be	112
unreasonable or inconsistent with patient safety within a	113
reasonable amount of time, the board shall recommend to the	114
superintendent that the superintendent fine the insurer or	115
administrator for noncompliance with the board's directive.	116

(G) The superintendent may fine an insurer or administrator	117
for noncompliance with the board's directive after a hearing under	118
Chapter 119. of the Revised Code.	119

(H) Each contract issued by an insurer or administrator shall	120
include a provision that allows the insurer or administrator to	121
amend the terms of the contract as directed by the board.	122

(I) The board shall annually report to the superintendent of	123
insurance information related to external reviews, as required	124
under section 3922.17 of the Revised Code and shall submit the	125
report to the superintendent of insurance.	126

(J) As used in this section:

127

(1) "Insurer" means a health insuring corporation, sickness	128
and accident insurer, multiple employer welfare arrangement,	129
self-insured employer, administrator of a self-insured plan, or	130
public employee benefit plan.	131

(2) "Administrator" has the same meaning as in section	132
3959.01 of the Revised Code.	133

(3) "Trade association" means a statewide or national	134
association that represents professionals in the field of medicine	135
and includes the Ohio state medical association, the Ohio	136
psychological association, the Ohio podiatric medical association,	137
the Ohio hospital association, or the American nurses association.	138
"Trade association" does not mean a labor organization, as defined	139
under section 3517.01 of the Revised Code.	140

Sec. 3922.01.  As used in this chapter:

141

(A) "Adverse benefit determination" means a decision by a	142
health plan issuer:	143

(1) To deny, reduce, or terminate a requested health care	144
service or payment in whole or in part, including all of the	145
following:	146

(a) A determination that the health care service does not	147
meet the health plan issuer's requirements for medical necessity,	148
appropriateness, health care setting, level of care, or	149
effectiveness, including experimental or investigational	150
treatments;	151

(b) A determination of an individual's eligibility for	152
individual health insurance coverage, including coverage offered	153
to individuals through a nonemployer group, to participate in a	154
plan or health insurance coverage;	155

(c) A determination that a health care service is not a	156
covered benefit;	157

(d) The imposition of an exclusion, including exclusions for	158
pre-existing conditions, source of injury, network, or any other	159
limitation on benefits that would otherwise be covered.	160

(2) Not to issue individual health insurance coverage to an	161
applicant, including coverage offered to individuals through a	162
nonemployer group;	163

(3) To rescind coverage on a health benefit plan.

164

(B) "Ambulatory review" has the same meaning as in section	165
1751.77 of the Revised Code.	166

(C) "Authorized representative" means an individual who	167
represents a covered person in an internal appeal or external	168
review process of an adverse benefit determination who is any of	169
the following:	170

(1) A person to whom a covered individual has given express,	171
written consent to represent that individual in an internal	172
appeals process or external review process of an adverse benefit	173
determination;	174

(2) A person authorized by law to provide substituted consent	175
for a covered individual;	176

(3) A family member or a treating health care professional,	177
but only when the covered person is unable to provide consent.	178

(D) "Best evidence" means evidence based on all of the	179
following sources, listed according to priority, as they are	180
available:	181

(1) Randomized clinical trials;

182

(2) Cohort studies or case-control studies;

183

(3) Case series;

184

(4) Expert opinion.

185

(E) "Clinical peer" means a medical provider with expertise	186
in the appropriate medical specialty and who holds a license or	187
certificate in good standing with the relevant state licensing or	188
certifying authority when an evaluation is to be made of the	189
clinical appropriateness of health care services provided by a	190
physician. If an evaluation is to be made of the clinical	191
appropriateness of health care services provided by a provider who	192
is not a physician, "clinical peer" means either a physician or a	193
provider holding the same license or certificate as the provider	194
who provided the health care services.	195

(F) "Covered person" means a policyholder, subscriber,	196
enrollee, member, or individual covered by a health benefit plan.	197
"Covered person" does include the covered person's authorized	198
representative with regard to an internal appeal or external	199
review in accordance with division (C) of this section. "Covered	200
person" does not include the covered person's representative in	201
any other context.	202

(F)(G) "Covered benefits" or "benefits" means those health	203
care services to which a covered person is entitled under the	204
terms of a health benefit plan.	205

(G)(H) "Emergency medical condition" has the same meaning as	206
in section 1753.28 of the Revised Code.	207

(H)(I) "Emergency services" has the same meaning as in	208
section 1753.28 of the Revised Code.	209

(I)(J) "Evidence-based standard" means the conscientious,	210
explicit, and judicious use of the current best evidence, based on	211
a systematic review of the relevant research, in making decisions	212
about the care of individuals.	213

(J)(K) "Facility" means an institution providing health care	214
services, or a health care setting, including hospitals and other	215
licensed inpatient centers, ambulatory, surgical, treatment,	216
skilled nursing, residential treatment, diagnostic, laboratory,	217
and imaging centers, and rehabilitation and other therapeutic	218
health settings.	219

(K)(L) "Final adverse benefit determination" means an adverse	220
benefit determination that is upheld at the completion of a health	221
plan issuer's internal appeals process.	222

(L)(M) "Health benefit plan" means a policy, contract,	223
certificate, or agreement offered by a health plan issuer to	224
provide, deliver, arrange for, pay for, or reimburse any of the	225
costs of health care services, including benefit plans marketed in	226
the individual or group market by all associations, whether bona	227
fide or non-bona fide. "Health benefit plan" also means a limited	228
benefit plan, except as follows. "Health benefit plan" does not	229
mean any of the following types of coverage: a policy, contract,	230
certificate, or agreement that covers only a specified accident,	231
accident only, credit, dental, disability income, long-term care,	232
hospital indemnity, supplemental coverage, as described in section	233
3923.37 of the Revised Code, specified disease, or vision care;	234
coverage issued as a supplement to liability insurance; insurance	235
arising out of workers' compensation or similar law; automobile	236
medical payment insurance; or insurance under which benefits are	237
payable with or without regard to fault and which is statutorily	238
required to be contained in any liability insurance policy or	239
equivalent self-insurance; a medicare supplement policy of	240
insurance, as defined by the superintendent of insurance by rule,	241
coverage under a plan through medicare, medicaid, or the federal	242
employees benefit program; any coverage issued under Chapter 55 of	243
Title 10 of the United States Code and any coverage issued as a	244
supplement to that coverage.	245

(M)(N) "Health care professional" means a physician,	246
psychologist, nurse practitioner, or other health care	247
practitioner licensed, accredited, or certified to perform health	248
care services consistent with state law.	249

(N)(O) "Health care provider" or "provider" means a health	250
care professional or facility.	251

(O)(P) "Health care services" means services for the	252
diagnosis, prevention, treatment, cure, or relief of a health	253
condition, illness, injury, or disease.	254

(P)(Q) "Health plan issuer" means an entity subject to the	255
insurance laws and rules of this state, or subject to the	256
jurisdiction of the superintendent of insurance, that contracts,	257
or offers to contract to provide, deliver, arrange for, pay for,	258
or reimburse any of the costs of health care services under a	259
health benefit plan, including a sickness and accident insurance	260
company, a health insuring corporation, a fraternal benefit	261
society, a self-funded multiple employer welfare arrangement, or a	262
nonfederal, government health plan. "Health plan issuer" includes	263
a third party administrator licensed under Chapter 3959. of the	264
Revised Code to the extent that the benefits that such an entity	265
is contracted to administer under a health benefit plan are	266
subject to the insurance laws and rules of this state or subject	267
to the jurisdiction of the superintendent.	268

(Q)(R) "Health information" means information or data,	269
whether oral or recorded in any form or medium, and personal facts	270
or information about events or relationships that relates to all	271
of the following:	272

(1) The past, present, or future physical, mental, or	273
behavioral health or condition of a covered person or a member of	274
the covered person's family;	275

(2) The provision of health care services or health-related	276
benefits to a covered person;	277

(3) Payment for the provision of health care services to or	278
for a covered person.	279

(R) "Independent review organization" means an entity that is	280
accredited to conduct independent external reviews of adverse	281
benefit determinations pursuant to section 3922.13 of the Revised	282
Code.	283

(S) "Medical or scientific evidence" means evidence found in	284
any of the following sources:	285

(1) Peer-reviewed scientific studies published in, or	286
accepted for publication by, medical journals that meet nationally	287
recognized requirements for scientific manuscripts and that submit	288
most of their published articles for review by experts who are not	289
part of the editorial staff;	290

(2) Peer-reviewed medical literature, including literature	291
relating to therapies reviewed and approved by a qualified	292
institutional review board, biomedical compendia and other medical	293
literature that meet the criteria of the national institutes of	294
health's library of medicine for indexing in index medicus and	295
elsevier science ltd. for indexing in excerpta medicus;	296

(3) Medical journals recognized by the secretary of health	297
and human services under section 1861(t)(2) of the federal social	298
security act;	299

(4) The following standard reference compendia:

300

(a) The American hospital formulary service drug information;

301

(b) Drug facts and comparisons;

302

(c) The American dental association accepted dental	303
therapeutics;	304

(d) The United States pharmacopoeia drug information.

305

(5) Findings, studies or research conducted by or under the	306
auspices of a federal government agency or nationally recognized	307
federal research institute, including any of the following:	308

(a) The federal agency for health care research and quality;

309

(b) The national institutes of health;

310

(c) The national cancer institute;

311

(d) The national academy of sciences;

312

(e) The centers for medicare and medicaid services;

313

(f) The federal food and drug administration;

314

(g) Any national board recognized by the national institutes	315
of health for the purpose of evaluating the medical value of	316
health care services.	317

(6) Any other medical or scientific evidence that is	318
comparable.	319

(T) "Person" has the same meaning as in section 3901.19 of	320
the Revised Code.	321

(U) "Protected health information" means health information	322
related to the identity of an individual, or information that	323
could reasonably be used to determine the identity of an	324
individual.	325

(V) "Rescind" means to retroactively cancel or discontinue	326
coverage. "Rescind" does not include canceling or discontinuing	327
coverage that only has a prospective effect or canceling or	328
discontinuing coverage that is effective retroactively to the	329
extent it is attributable to a failure to timely pay required	330
premiums or contributions towards the cost of coverage.	331

(W) "Retrospective review" means a review conducted after	332
services have been provided to a covered person.	333

(X) "Superintendent" means the superintendent of insurance.

334

(Y) "Utilization review" has the same meaning as in section	335
1751.77 of the Revised Code.	336

(Z) "Utilization review organization" has the same meaning as	337
in section 1751.77 of the Revised Code.	338

Sec. 3922.03.  (A) All health plan issuers shall implement an	339
internal appeal process under which a covered person may appeal an	340
adverse benefit determination. This process must be in compliance	341
with the "Patient Protection and Affordable Care Act of 2010,"	342
Pub. L. 111-148, 124 Stat. 119, as amended, and the associated	343
regulations, as well as any other applicable state laws or rules	344
or federal regulations.	345

(B) A health insuring corporation shall consider and provide	346
a written response to each request for a nonexpedited internal	347
review not later than fourteen days after receipt of the request.	348

(C) Review of a final adverse benefit determination shall be	349
through an external review under section 3922.08, 3922.09, or	350
3922.10 of the Revised Code.	351

(C)(D) All health plan issuers shall provide notice to	352
covered persons, pursuant to and in accordance with federal	353
regulations, of all internal appeal processes, external review	354
processes, the availability of any applicable office of health	355
insurance assistance, ombudsman program, or other similar program	356
in this state to assist consumers.	357

Sec. 3922.05.  (A) A health plan issuer shall afford the	358
opportunity for an external review by an independent review	359
organizationa panel of three clinical peers appointed by the Ohio	360
health insurance oversight board for an adverse benefit	361
determination if the determination involved a medical judgment or	362
if the decision was based on any medical information, pursuant to	363
the following sections:	364

(1) Section 3922.08 of the Revised Code for a standard	365
review;	366

(2) Section 3922.09 of the Revised Code for an expedited	367
review;	368

(3) Section 3922.10 of the Revised Code for reviews involving	369
experimental procedures.	370

(B) A health plan issuer shall afford the opportunity for an	371
external review by the superintendent of insurance for an adverse	372
benefit determination by the health plan issuer based on a	373
contractual issue that did not involve a medical judgment or any	374
medical information, pursuant to section 3922.11 of the Revised	375
Code.	376

(C) For an adverse benefit determination in which emergency	377
medical services have been determined to be not medically	378
necessary or appropriate after an external review pursuant to	379
division (A) of this section, the health plan issuer shall afford	380
the covered person the opportunity for an external review by the	381
superintendent of insurance, based on the prudent layperson	382
standard, pursuant to section 3922.11 of the Revised Code.	383

(D) Upon receipt of a request for an external review from a	384
covered person, the health plan issuer shall review it for	385
completeness as prescribed under any associated rules, policies,	386
or procedures adopted by the superintendent.	387

(1) If the request is complete, the health plan issuer shall	388
initiate an external review in accordance with any associated	389
rules, policies, or procedures adopted by the superintendent of	390
insurance and shall notify the covered person in writing, in a	391
form specified by the superintendent of insurance, that the	392
request is complete. This notification shall include both of the	393
following:	394

(a) The name and contact information for the assigned	395
independent review organizationOhio health insurance oversight	396
board or the superintendent of insurance, as applicable, for the	397
purpose of submitting additional information;	398

(b) Except for when an expedited request is made under	399
section 3922.09 or 3922.10 of the Revised Code, a statement that	400
the covered person may, within ten business days after the date of	401
receipt of the notice, submit, in writing, additional information	402
forto either the independent review organizationOhio health	403
insurance oversight board or the superintendent of insurance to	404
consider when conducting the external review.	405

(2) If the Ohio health insurance oversight board receives	406
additional information under division (D)(1) of this section, the	407
board shall provide this information to the relevant panel of	408
clinical peers;	409

(3) If the request for an external review is not complete,	410
the health plan issuer shall, in accordance with any associated	411
rules, policies, or procedures adopted by the superintendent of	412
insurance, inform the covered person in writing, including what	413
information is needed to make the request complete.	414

(E)(1) If the health plan issuer denies a request for an	415
external review on the basis that the adverse benefit	416
determination is not eligible for an external review, the health	417
plan issuer shall notify the covered person in writing of both of	418
the following:	419

(a) The reason for the denial;

420

(b) That the denial may be appealed to the superintendent.

421

(2) If the health plan issuer denies a request for external	422
review on the basis that the adverse benefit determination is not	423
eligible for an external review, the covered person may appeal the	424
denial to the superintendent of insurance.	425

(3) Regardless of a determination made by a health plan	426
issuer, the superintendent of insurance may determine that a	427
request is eligible for external review. The superintendent's	428
determination shall be made in accordance with the terms of the	429
covered person's benefit plan and shall be subject to all	430
applicable provisions of this chapter.	431

(F) The Ohio health insurance oversight board shall maintain	432
a randomly organized roster of clinical specialists recommended by	433
the Ohio state medical association or a statewide or national	434
medical specialty board that represents clinical specialists for	435
the purpose of selecting clinical peers to conduct external	436
reviews. The board may, in accordance with Chapter 119. of the	437
Revised Code, adopt rules governing the selection of clinical	438
peers.	439

(G)(1) If an external review of an adverse benefit	440
determination is granted, the superintendentOhio health insurance	441
oversight board, according to any rules, policies, or procedures	442
adopted by the superintendent of insurance shall assign an	443
independent review organizationappoint a panel of three clinical	444
peers from the list of organizationsclinical peers maintained by	445
the superintendentOhio health insurance oversight board under	446
division (F) of this section 3922.13 of the Revised Code to	447
conduct the external review and shall notify the health plan	448
issuer of the namenames of the assigned independent review	449
organizationappointed clinical peers.	450

(2) The assignmentappointment of an approved independent	451
review organizationa panel of clinical peers shall be done on a	452
random basis from those independent review organizationsclinical	453
peers qualified to conduct the review in question based on the	454
nature of the health care service that is the subject of the	455
adverse benefit determination.	456

(3) The superintendent of insuranceOhio health insurance	457
oversight board shall not choose an independent review	458
organizationappoint a clinical peer with a conflict of interest,	459
as prescribed under section 3922.14 of the Revised Code.	460

(G)(H) In its review of an adverse benefit determination	461
under section 3922.08, 3922.09, or 3922.10 of the Revised Code, an	462
assigned independent review organizationappointed panel of	463
clinical peers is not bound by any decisions or conclusions	464
reached by the health plan issuer during its utilization review	465
process or internal appeals process. The organizationpanel is	466
not required to, but may, accept and consider additional	467
information submitted after the end of the ten-business-day period	468
described in division (D)(1)(b) of this section.	469

(H)(I)(1) An independent review organization assignedA panel	470
of clinical peers appointed to review an adverse benefit	471
determination shall provide written notice of its decision to	472
either uphold or reverse the determination within thirty days of	473
receipt by the health plan issuer of a request for a standard	474
review or a standard review involving an experimental or	475
investigational treatment, or within seventy-two hours of receipt	476
by the health plan issuer of an expedited request.	477

(2) The written notice shall be sent to all of the following:

478

(a) The covered person;

479

(b) The health plan issuer;

480

(c) The superintendent of insurance;

481

(d) The Ohio health insurance oversight board.

482

(3) The written notification shall include all of the	483
following:	484

(a) A general description of the reason for the request for	485
external review;	486

(b) The date the independent review organizationpanel of	487
clinical peers was assignedappointed by the superintendent of	488
insuranceOhio health insurance oversight board to conduct the	489
external review;	490

(c) The dates over which the external review was conducted;

491

(d) The date on which the independent review organization's	492
panel of clinical peers' decision was made;	493

(e) The rationale for its decision;

494

(f) References to the evidence or documentation, including	495
any evidence-based standards used, that were considered in	496
reaching its decision.	497

(I)(J) Upon receipt of a notice by an independent review	498
organizationa panel of clinical peers to reverse the adverse	499
benefit determination, a health plan issuer shall immediately	500
provide coverage for the health care service or services in	501
question.	502

(K) If an adverse benefit determination is overturned under	503
this chapter, the superintendent of insurance shall levy against	504
the health plan issuer in question a fine equal to three times the	505
cost of the medical care provided under division (J) of this	506
section. Any such fees collected under this section shall be paid	507
into the state treasury and credited to the department of	508
insurance operating fund created by section 3901.021 of the	509
Revised Code.	510

Sec. 3922.06. Except for when an expedited request is made	511
under section 3922.09 or 3922.10 of the Revised Code, an	512
independent review organizationthe Ohio health insurance	513
oversight board shall forward upon receipt a copy of any	514
information received from a covered person pursuant to division	515
(D)(1) of section 3922.05 of the Revised Code, as well as any	516
other information received from the covered person, to the health	517
plan issuer.	518

Upon receipt of that information or the information described	519
in division (K)(J) of section 3922.10 of the Revised Code, a	520
health plan issuer may reconsider its adverse benefit	521
determination and provide coverage for the health service in	522
question.	523

Reconsideration of an adverse benefit determination by a	524
health plan issuer based upon receipt of information under this	525
section shall not delay or terminate an external review.	526

If a health plan issuer reverses an adverse benefit	527
determination under this section, the health plan issuer shall	528
notify, in writing and within one business day of making such a	529
decision, the covered person, the assigned independent review	530
organizationappointed panel of clinical peers, the Ohio health	531
insurance oversight board, and the superintendent of insurance.	532

Upon receipt of such a notification, the assigned independent	533
review organizationpanel of clinical peers shall terminate the	534
associated external review.	535

Sec. 3922.07.  In addition to the information provided under	536
division (D)(1)(b) of section 3922.05, division (B) of section	537
3922.08, division (C) of section 3922.09, and division (D) of	538
section 3922.10 of the Revised Code, an assigned independent	539
review organizationappointed panel of clinical peers, to the	540
extent that such documents are available and appropriate, shall	541
consider all of the following when conducting its review:	542

(A) The covered person's medical records;

543

(B) The attending health care professional's recommendation;

544

(C) Consulting reports from appropriate health care	545
professionals and other documents submitted by the health plan	546
issuer, covered person, or covered person's treating provider;	547

(D) The terms of coverage under the covered person's health	548
benefit plan to ensure that the independent review organization's	549
panel of clinical peers' decision is not contrary to the terms of	550
the plan;	551

(E) The most appropriate practice guidelines, including	552
evidence-based standards, and practice guidelines developed by the	553
federal government, and national or professional medical	554
societies, boards, and associations;	555

(F) Any applicable clinical review criteria developed and	556
used by the health plan issuer or its designated utilization	557
review organization;	558

(G) The opinion of the independent review organization's	559
clinical reviewer or reviewers after considering the other sources	560
described in this section.	561

Sec. 3922.08.  (A) The provisions of this section apply only	562
to standard reviews, which are not expedited and do not involve an	563
experimental or investigational treatment.	564

(B) Within five days after the receipt of a request for an	565
external review that is complete and valid, the health plan issuer	566
shall provide to the assigned independent review organization	567
appointed panel of clinical peers all documents and information	568
considered in making the adverse benefit determination.	569

(C) An external review shall not be delayed due to failure on	570
the part of the health plan issuer to provide the information	571
required under division (B) of this section.	572

(D)(1) An independent review organizationA panel of clinical	573
peers may reverse an adverse benefit determination if the	574
information required under division (B) of this section is not	575
provided in the allotted time. The independent review organization	576
panel of clinical peers may also grant a request from the health	577
plan issuer for more time to provide the required information.	578

(2) If an adverse benefit determination is reversed under	579
division (D)(1) of this section, the independent review	580
organizationpanel of clinical peers shall notify, within one	581
business day of making the decision, the covered person, the	582
health plan issuer, and the superintendent of insurance, and the	583
Ohio health insurance oversight board.	584

Sec. 3922.09.  (A) A covered person may make a request for an	585
expedited external review, except as provided in division (I) of	586
this section:	587

(1) After an adverse benefit determination, if both of the	588
following apply:	589

(a) The covered person's treating physician certifies that	590
the adverse benefit determination involves a medical condition	591
that could seriously jeopardize the life or health of the covered	592
person, or would jeopardize the covered person's ability to regain	593
maximum function, if treated after the time frame of an expedited	594
internal appeal;	595

(b) The covered person has filed a request for an expedited	596
internal appeal.	597

(2) After a final adverse benefit determination, if either of	598
the following apply:	599

(a) The covered person's treating physician certifies that	600
the adverse benefit determination involves a medical condition	601
that could seriously jeopardize the life or health of the covered	602
person, or would jeopardize the covered person's ability to regain	603
maximum function, if treated after the time frame of a standard	604
external review;	605

(b) The final adverse benefit determination concerns an	606
admission, availability of care, continued stay, or health care	607
service for which the covered person received emergency services,	608
but has not yet been discharged from a facility.	609

(B) Immediately upon receipt of a request for an expedited	610
external review, the health plan issuer shall determine if the	611
request is complete under any associated rules, policies, or	612
procedures adopted by the superintendent of insurance and eligible	613
for expedited external review under division (A) of this section.	614
The health plan issuer shall immediately notify the covered person	615
of its determination in accordance with any associated rules,	616
policies, or procedures adopted by the superintendent of	617
insurance.	618

(C) If a request for an expedited review is complete and	619
eligible, the health plan issuer shall immediately provide or	620
transmit all necessary documents and information considered in	621
making the adverse benefit determination in question to the	622
assigned independent review organizationpanel of clinical peers	623
appointed by the Ohio health insurance oversight board	624
electronically, or by facsimile or other available expeditious	625
method.	626

(D) In addition to the information transmitted under division	627
(C) of this section, the assigned independent review organization	628
appointed panel of clinical peers shall also consider relevant	629
information as required under section 3922.07 of the Revised Code.	630

(E) As expeditiously as the covered person's medical	631
condition requires, but no more than seventy-two hours after	632
receipt by the health plan issuer of a request for an expedited,	633
external review, the assigned independent review organization	634
appointed panel of clinical peers shall uphold or reverse the	635
adverse benefit determination.	636

(F) If a health plan issuer fails to provide the documents	637
and information as required in division (C) of this section, the	638
independent review organizationpanel of clinical peers shall not	639
delay the external review and may accordingly reverse the adverse	640
benefit determination.	641

(G) An independent review organizationThe appointed panel of	642
clinical peers shall promptly notify the covered person, health	643
plan issuer, andthe superintendent of insurance, and the Ohio	644
health insurance oversight board of any decision made under this	645
section. If such a notice is not made in writing, the independent	646
review organizationpanel of clinical peers, shall provide, within	647
forty-eight hours of making the decision, written confirmation,	648
including the information required under division (H)(I)(3) of	649
section 3922.05 of the Revised Code, of its decision to the	650
covered person, the health plan issuer, and the superintendent of	651
insurance, and the Ohio health insurance oversight board.	652

(H) Upon receipt of a notice by an independent review	653
organizationa panel of clinical peers to reverse the adverse	654
benefit determination, a health plan issuer shall immediately	655
provide coverage for the health care service or services in	656
question.	657

(I) An expedited, external review may not be provided for	658
retrospective final adverse benefit determinations.	659

Sec. 3922.10.  The provisions of this section apply only to	660
external reviews that involve an experimental or investigational	661
treatment.	662

(A) A covered person may request an external review of an	663
adverse benefit determination based on the conclusion that a	664
requested health care service is experimental or investigational,	665
except when the requested health care service is explicitly listed	666
as an excluded benefit under the covered person's benefit plan.	667

(B) To be eligible for an external review under this section,	668
a covered person's treating physician shall certify that one of	669
the following situations is applicable:	670

(1) Standard health care services have not been effective in	671
improving the condition of the covered person.	672

(2) Standard health care services are not medically	673
appropriate for the covered person.	674

(3) There is no available standard health care service	675
covered by the health plan issuer that is more beneficial than the	676
requested health care service.	677

(C)(1) A covered person may request orally or by electronic	678
means an expedited review under this section if the person's	679
treating physician certifies that the requested health care	680
service in question would be significantly less effective if not	681
promptly initiated.	682

(2) Immediately upon receipt of a request for an expedited	683
external review, the health plan issuer shall determine if the	684
request is complete under any associated rules, policies, or	685
procedures adopted by the superintendent of insurance and eligible	686
for expedited external review under division (C)(1) of this	687
section. The health plan issuer shall immediately notify the	688
covered person of its determination in accordance with any	689
associated rules adopted by the superintendent of insurance.	690

(D) The health plan issuer shall provide to the assigned	691
independent review organizationappointed panel of clinical peers	692
all documents and information considered in making the adverse	693
benefit determination within whichever of the following applies:	694

(1) Within five days after the receipt of a request for a	695
standard external review;	696

(2) For an expedited external review, immediately	697
electronically, or by facsimile or any other available expeditious	698
method.	699

(E) An independent review organization assigned by the	700
superintendent of insurance under division (F) of section 3922.05	701
of the Revised Code shall do both of the following:	702

(1) Select at least one clinical reviewer, pursuant to	703
divisions (F) and (G) of this section to conduct the external	704
review;	705

(2) Make a decision to uphold or reverse the adverse benefit	706
determination based upon the opinion of the clinical reviewer or	707
reviewers.	708

(F) In selecting clinical reviewers under division (E) ofa	709
panel of clinical peers under this section, the assigned	710
independent review organizationOhio health insurance oversight	711
board shall select physicians or other health care professionals	712
who meet the minimum qualifications described in section 3922.15	713
of the Revised Code.	714

(G)(F) Neither the covered person, nor the health plan	715
issuer, shall choose or have any influence over the choice of the	716
clinical reviewer or reviewerspeers chosen under division (E) of	717
this sectionby the Ohio health insurance oversight board.	718

(H)(G)(1) Each chosen clinical reviewerpeer shall provide a	719
written opinion to the assigned independent review organization	720
Ohio health insurance oversight board on whether the adverse	721
benefit determination should be upheld or reversed.	722

(2) In reaching such opinions, a clinical reviewerpeer is	723
not bound by any conclusions reached by the health plan issuer	724
during a utilization review process or its internal appeals	725
process.	726

(3) Any such opinion shall be in writing and shall include	727
all of the following information:	728

(a) A description of the covered person's condition;

729

(b) A description of the indicators relevant to determining	730
whether there is sufficient evidence to demonstrate that the	731
recommended or requested therapy is more likely than not to be	732
more beneficial to the covered person than any available standard	733
health care service, and that the adverse risks of the requested	734
health care service would not be substantially greater than those	735
of available standard health care services;	736

(c) A description and analysis of any medical or scientific	737
evidence considered in reaching the opinion;	738

(d) A description and analysis of any evidence-based standard	739
considered;	740

(e) Information on whether the reviewer's rationale for the	741
opinion is based on division (K)(J)(2)(b) or (c) of this section.	742

(I)(H) An external review shall not be delayed due to failure	743
on the part of the health plan issuer to provide the information	744
required under division (D) of this section.	745

(J)(I)(1) An independent review organizationA panel of	746
clinical peers may reverse an adverse benefit determination, if	747
the information required under division (D) of this section is not	748
provided in the allotted time. The independent review organization	749
panel of clinical peers may also grant a request from the health	750
plan issuer for more time to provide the required information.	751

(2) If an adverse benefit determination is reversed under	752
division (J)(I)(1) of this section, the independent review	753
organizationpanel of clinical peers shall immediately notify the	754
covered person, the health plan issuer, the Ohio health insurance	755
oversight board, and the superintendent of insurance.	756

(K)(J)(1) Each clinical reviewerpeer shall review all of the	757
information received pursuant to division (D) of this section, as	758
well as any other information submitted in writing by the covered	759
person pursuant to division (D) of section 3922.05 of the Revised	760
Code.	761

(2) In addition to the documents and information provided	762
pursuant to division (D) of this section and division (D) of	763
section 3922.05 of the Revised Code, each clinical reviewerpeer	764
shall consider the following:	765

(a) Information required under section 3922.07 of the Revised	766
Code;	767

(b) Whether the requested health care service has been	768
approved by the federal food and drug administration, if	769
applicable, for the condition;	770

(c) Whether medical or scientific evidence, or evidence-based	771
standards, demonstrate that the expected benefits of the requested	772
health care service is more likely than not to be beneficial to	773
the covered person than any available standard health care	774
service, and that the adverse risks of the requested health care	775
service would not be substantially greater than those of available	776
standard health care services.	777

(L)(K) Within one business day after the receipt of any such	778
information submitted by the covered person in accordance with	779
division (K)(J)(1) of this section, the independent review	780
organizationpanel of clinical peers shall forward the information	781
to the health plan issuer. Upon receipt of any such forwarded	782
information in accordance with division (K)(J)(1) of this section,	783
a health plan issuer may reconsider its adverse benefit	784
determination as described in section 3922.06 of the Revised Code.	785

(M)(L)(1) Within thirty days after the date of receipt by the	786
health plan issuer of a request for a standard external review, or	787
within seventy-two hours of receipt by the health plan issuer of a	788
request for an expedited external review, the assigned independent	789
review organizationappointed panel of clinical peers shall	790
provide written notice of its decision to uphold or reverse the	791
adverse benefit determination to the covered person, the health	792
plan issuer, the Ohio health insurance oversight board, and the	793
superintendent of insurance.	794

(2)(a) If a majority of the clinical reviewerspeers	795
recommend that the requested health care service should be	796
covered, the independent review organizationpanel of clinical	797
peers shall make a decision to reverse the health plan issuer's	798
adverse benefit determination.	799

(b) If a majority of the clinical reviewerspeers recommend	800
that the recommended or requested health care service or treatment	801
should not be covered, the independent review organizationpanel	802
of clinical peers shall make a decision to uphold the health plan	803
issuer's adverse benefit determination.	804

(c)(i) If the clinical reviewers are evenly split as to	805
whether the adverse benefit determination should be reversed or	806
upheld, the independent review organization shall obtain the	807
opinion of an additional clinical reviewer in order for the	808
independent review organization to make a decision based on the	809
opinions of a majority of the clinical reviewers pursuant to this	810
division.	811

(ii) The additional clinical reviewer selected shall use the	812
same information to reach an opinion as the clinical reviewers who	813
have already submitted their opinions pursuant to this section.	814

(iii) The selection of the additional clinical reviewer under	815
this division shall not extend the time within which the assigned	816
independent review organization is required to make a decision.	817

(3) The independent review organizationpanel of clinical	818
peers shall include in the notice provided pursuant to division	819
(M)(L)(1) of this section all of the following:	820

(a) A general description of the reason for the request for	821
external review;	822

(b) The written opinion of each clinical reviewerpeer,	823
including the recommendation of each clinical reviewerpeer as to	824
whether the recommended or requested health care service or	825
treatment should be covered and the rationale for that	826
recommendation;	827

(c) The date the independent review organizationpanel of	828
clinical peers was assignedappointed by the superintendentOhio	829
health insurance oversight board to conduct the external review;	830

(d) The dates over which the external review was conducted;

831

(e) The date of its decision;

832

(f) The principal reason or reasons for its decision;

833

(g) The rationale for its decision.

834

(N)(M) Upon receipt of a notice of a decision by an	835
independent review organizationpanel of clinical peers pursuant	836
to division (M)(L)(1) of this section reversing the adverse	837
benefit determination, a health plan issuer shall immediately	838
provide coverage of the requested health care service in question.	839

Sec. 3922.14.  (A) To be accredited by the superintendent of	840
insurance to conduct external reviews under section 3922.13 of the	841
Revised Code, in addition to the requirements provided in section	842
3922.13 of the Revised Code and any associated rules adopted by	843
the superintendent, an independent review organization shall do	844
all of the following:	845

(1) Develop and maintain written policies and procedures that	846
govern all aspects of both the standard external review process	847
and the expedited external review process set forth in this	848
chapter, including a quality assurance mechanism that does all of	849
the following:	850

(a) Ensures that external reviews are conducted within the	851
time frames prescribed under this chapter and that the required	852
notices are provided in a timely manner;	853

(b) Ensures the selection of qualified and impartial clinical	854
reviewers to conduct external reviews on behalf of the independent	855
review organization;	856

(c) Ensures that chosen clinical reviewers are suitably	857
matched according to their area of expertise to specific cases and	858
that the independent review organization employs or contracts with	859
an adequate number of clinical reviewers to meet this requirement;	860

(d) Ensures the confidentiality of medical and treatment	861
records and clinical review criteria;	862

(e) Ensures that any person employed by, or who is under	863
contract with, the independent review organization adheres to the	864
requirements of this chapter.	865

(2) Maintain a toll-free telephone service to receive	866
information on a twenty-four-hour-a-day, seven-days-a-week basis	867
related to external reviews that is capable of accepting,	868
recording, and providing appropriate instruction to incoming	869
telephone callers during other than normal business hours;	870

(3) Agree to maintain and provide to the superintendent, upon	871
request and in accordance with any associated rules, policies, or	872
procedures adopted by the superintendent of insurance, the	873
information prescribed in section 3922.17 of the Revised Code.	874

(B) An independent review organizationA clinical peer may	875
not own or control, be a subsidiary of or in any way be owned or	876
controlled by, or exercise control with a health plan issuer, a	877
national, state, or local trade association of health plan	878
issuers, or a national, state, or local trade association of	879
health care providers.	880

(C)(B)(1) Neither the independent review organization	881
selected to conduct the external review nor anyNo clinical	882
reviewer assignedpeer appointed by the independent organization	883
Ohio health insurance oversight board to conduct the external	884
review may have a material, professional, familial, or financial	885
affiliation with any of the following:	886

(a) The health plan issuer that is the subject of the	887
external review, or any officer, director, or management employee	888
of the health plan issuer;	889

(b) The covered person whose treatment is the subject of the	890
external review;	891

(c) The health care provider, or the health care provider's	892
medical group or independent practice association, recommending	893
the health care service or treatment that is the subject of the	894
external review;	895

(d) The facility at which the recommended health care service	896
would be provided;	897

(e) The developer or manufacturer of the principal drug,	898
device, procedure, or other therapy being recommended for the	899
covered person whose treatment is the subject of the external	900
review.	901

(2) The superintendent may make a determination as to whether	902
an independent review organization or a clinical reviewer of the	903
independent review organizationpeer has a material professional,	904
familial, or financial conflict of interest for purposes of	905
division (C)(B)(1) of this section. In making this determination,	906
the superintendent may take into consideration situations where an	907
independent review organization, or a clinical reviewerpeer, may	908
have an apparent conflict of interest, but that the	909
characteristics of the relationship or connection in question are	910
such that they do not fall under the definition ofconstitute an	911
actual conflict of interest provided under division (D)(1) of this	912
section. If the superintendent determines that a conflict of	913
interest exists, the superintendent shall disallow an independent	914
review organization or a clinical reviewerpeer from conducting	915
the external review in question. Such determinations related to	916
conflicts of interest are the sole discretion of the	917
superintendent of insurance.	918

(D)(1) An independent review organization that is accredited	919
by a nationally recognized private accrediting entity that has	920
independent review accreditation standards that the superintendent	921
has determined are equivalent to or exceed the minimum	922
qualifications of this section shall be presumed in compliance	923
with this section to be eligible for accreditation by the	924
superintendent under section 3922.14 of the Revised Code.	925

(2) The superintendent shall initially review and	926
periodically review the independent review organization	927
accreditation standards of a nationally recognized private	928
accrediting entity to determine whether the entity's standards	929
are, and continue to be, equivalent to or exceed the minimum	930
qualifications established under this section. The superintendent	931
may accept a review conducted by the national association of	932
insurance commissioners for the purpose of the determination under	933
this division.	934

(3) Upon request, a nationally recognized, private	935
accrediting entity shall make its current independent review	936
organization accreditation standards available to the	937
superintendent or the national association of insurance	938
commissioners in order for the superintendent to determine if the	939
entity's standards are equivalent to or exceed the minimum	940
qualifications established under this section. The superintendent	941
may exclude any private accrediting entity that is not reviewed by	942
the national association of insurance commissioners.	943

(E) An independent review organization(C) A panel of	944
clinical peers shall be unbiased in its review of adverse benefit	945
determinations and shall establish and maintain written procedures	946
to ensure that it is unbiased.	947

Sec. 3922.15.  All clinical reviewers assignedpeers	948
appointed by an independent review organizationthe Ohio health	949
insurance oversight board to conduct external reviews shall have	950
the same license as the health care provider of the service in	951
question, and shall be physicians or other appropriate health care	952
providers who meet all of the following minimum qualifications:	953

(A) Be an expert in the treatment of the medical condition	954
that is the subject of the external review;	955

(B) Be knowledgeable about the requested health care service	956
through clinical experience, within the last three years, treating	957
patients with the same, or a similar, medical condition, and, in	958
the case of an external review of an experimental or	959
investigational health care service, be an expert, through	960
clinical experience in the last three years, in the treatment of	961
the covered person's condition and have knowledge of the requested	962
health care service;	963

(C) Hold a nonrestricted license in a state of the United	964
States and, for physicians, a current certification by a	965
recognized American medical specialty board in the area or areas	966
appropriate to the subject of the external review;	967

(D) Have no history of disciplinary actions or sanctions,	968
including loss of staff privileges or participation restrictions,	969
that have been taken or are pending by any hospital, governmental	970
agency or unit, or regulatory body that raise a question as to the	971
clinical reviewer's physical, mental, or professional competence	972
or moral character.	973

Sec. 3922.16.  (A) Nothing in this chapter shall be construed	974
to create a cause of action against any of the following:	975

(1) An employer that provides health care benefits to	976
employees through a health plan issuer;	977

(2) A clinical reviewer or independent review organization	978
peer that participates in an external review under this chapter;	979

(3) A health plan issuer that provides coverage for benefits	980
pursuant to this chapter.	981

(B) An independent review organization and any clinical	982
reviewer an independent review organization uses in conducting an	983
external review under this chapterA clinical peer is not liable	984
in damages in a civil action for injury, death, or loss to person	985
or property and is not subject to professional disciplinary action	986
for making, in good faith, any finding, conclusion, or	987
determination required to complete the external review.	988

(C) This section does not grant immunity from civil liability	989
or professional disciplinary action to an independent review	990
organization or clinical reviewera clinical peer for an action	991
that is outside the scope of authority granted under this chapter.	992

Sec. 3922.17.  (A)(1) An independent review organization	993
assigned pursuant to sections 3922.08, 3922.09, or 3922.10 of the	994
Revised Code to conduct an external reviewThe Ohio health	995
insurance oversight board shall maintain written records in	996
accordance with the associated rules established by the	997
superintendent, in the aggregate by state, and by the health plan	998
issuer, on all external reviews requested and conducted during a	999
calendar year.	1000

Each independent review organizationThe Ohio health	1001
insurance oversight board shall annually submit this information	1002
to the superintendent, upon request, in a report in the format	1003
specified by the superintendent that shall include, in the	1004
aggregate by state and for each health plan issuer, all of the	1005
following:	1006

(a) The total number of requests for external review;

1007

(b) The number of requests for external review resolved and,	1008
of those resolved, the number upholding and the number reversing	1009
an adverse benefit determination;	1010

(c) The average length of time for a resolution;

1011

(d) A summary of the types of requested health care services	1012
or cases for which an external review was sought;	1013

(e) The number of external reviews that were terminated as	1014
the result of a reconsideration by the health plan issuer of an	1015
adverse benefit determination after the receipt of additional	1016
information from the covered person under section 3922.05 of the	1017
Revised Code;	1018

(f) The costs associated with external reviews, including the	1019
amounts charged by the independent review organizationpanels of	1020
clinical peers to conduct the reviews;	1021

(g) The medical specialty, or the type, of clinical reviewer	1022
peers used to conduct each external review, as related to the	1023
specific medical condition of the covered person;	1024

(h) Any other information the superintendent may request or	1025
require.	1026

(2) The independent review organizationOhio health insurance	1027
oversight board shall retain the written records required under	1028
division (A)(1) of this section for at least three years.	1029

(B) A health plan issuer shall maintain written records on	1030
all requests made for an external review under this chapter and	1031
shall provide all such information as required by any associated	1032
rules, policies, or procedures adopted by the superintendent of	1033
insurance. A health plan issuer shall maintain written records on	1034
all requests for external review for at least three years.	1035

(C) The superintendent shall compile and annually publish the	1036
information collected under this section and report the	1037
information to the governor, the speaker and minority leader of	1038
the house of representatives, the president and minority leader of	1039
the senate, and the chairs and ranking minority members of the	1040
house and senate committees with jurisdiction over health and	1041
insurance issues.	1042

Sec. 3922.20.  Consistent with the Rules of Evidence, a	1043
written decision or opinion prepared by an independent review	1044
organizationa panel of clinical peers under this chapter shall be	1045
admissible in any civil action related to the coverage decision	1046
that was the subject of the decision or opinion. The independent	1047
review organization'spanel of clinical peers' decision or	1048
opinion shall be presumed to be a scientifically valid and	1049
accurate description of the state of medical knowledge at the time	1050
it was written.	1051

Consistent with the Rules of Evidence, any party to a civil	1052
action related to a plan's decision involving an investigational	1053
or experimental drug, device, or treatment may introduce into	1054
evidence any applicable medicare reimbursement standards	1055
established under Title XVIII of the "Social Security Act," 49	1056
Stat. 620 (1935), 42 U.S.C.A. 301, as amended.	1057

Sec. 4731.36.  (A) Sections 4731.01 to 4731.47 of the Revised	1058
Code shall not prohibit service in case of emergency, domestic	1059
administration of family remedies, or provision of assistance to	1060
another individual who is self-administering drugs.	1061

Sections 4731.01 to 4731.47 of the Revised Code shall not	1062
apply to any of the following:	1063

(1) A commissioned medical officer of the United States armed	1064
forces, as defined in section 5903.11 of the Revised Code, or an	1065
employee of the veterans administration of the United States or	1066
the United States public health service in the discharge of the	1067
officer's or employee's professional duties;	1068

(2) A dentist authorized under Chapter 4715. of the Revised	1069
Code to practice dentistry when engaged exclusively in the	1070
practice of dentistry or when administering anesthetics in the	1071
practice of dentistry;	1072

(3) A physician or surgeon in another state or territory who	1073
is a legal practitioner of medicine or surgery therein when	1074
providing consultation to an individual holding a certificate to	1075
practice issued under this chapter who is responsible for the	1076
examination, diagnosis, and treatment of the patient who is the	1077
subject of the consultation, if one of the following applies:	1078

(a) The physician or surgeon does not provide consultation in	1079
this state on a regular or frequent basis.	1080

(b) The physician or surgeon provides the consultation	1081
without compensation of any kind, direct or indirect, for the	1082
consultation.	1083

(c) The consultation is part of the curriculum of a medical	1084
school or osteopathic medical school of this state or a program	1085
described in division (A)(2) of section 4731.291 of the Revised	1086
Code.	1087

(4) A physician or surgeon in another state or territory who	1088
is a legal practitioner of medicine or surgery therein and	1089
provided services to a patient in that state or territory, when	1090
providing, not later than one year after the last date services	1091
were provided in another state or territory, follow-up services in	1092
person or through the use of any communication, including oral,	1093
written, or electronic communication, in this state to the patient	1094
for the same condition;	1095

(5) A physician or surgeon residing on the border of a	1096
contiguous state and authorized under the laws thereof to practice	1097
medicine and surgery therein, whose practice extends within the	1098
limits of this state. Such practitioner shall not either in person	1099
or through the use of any communication, including oral, written,	1100
or electronic communication, open an office or appoint a place to	1101
see patients or receive calls within the limits of this state.	1102

(6) A board, committee, or corporation engaged in the conduct	1103
described in division (A) of section 2305.251 of the Revised Code	1104
when acting within the scope of the functions of the board,	1105
committee, or corporation;	1106

(7) The conduct of an independent review organization	1107
accredited by the superintendent of insurance under section	1108
3922.13 of the Revised Code for the purpose of external reviews	1109
conducted under Chapter 3922. of the Revised Code.	1110

(B) Sections 4731.51 to 4731.61 of the Revised Code do not	1111
apply to any graduate of a podiatric school or college while	1112
performing those acts that may be prescribed by or incidental to	1113
participation in an accredited podiatric internship, residency, or	1114
fellowship program situated in this state approved by the state	1115
medical board.	1116

(C) This chapter does not apply to an acupuncturist who	1117
complies with Chapter 4762. of the Revised Code.	1118

(D) This chapter does not prohibit the administration of	1119
drugs by any of the following:	1120

(1) An individual who is licensed or otherwise specifically	1121
authorized by the Revised Code to administer drugs;	1122

(2) An individual who is not licensed or otherwise	1123
specifically authorized by the Revised Code to administer drugs,	1124
but is acting pursuant to the rules for delegation of medical	1125
tasks adopted under section 4731.053 of the Revised Code;	1126

(3) An individual specifically authorized to administer drugs	1127
pursuant to a rule adopted under the Revised Code that is in	1128
effect on the effective date of this amendmentApril 10, 2001, as	1129
long as the rule remains in effect, specifically authorizing an	1130
individual to administer drugs.	1131

(E) The exemptions described in divisions (A)(3), (4), and	1132
(5) of this section do not apply to a physician or surgeon whose	1133
certificate to practice issued under this chapter is under	1134
suspension or has been revoked or permanently revoked by action of	1135
the state medical board.	1136

Section 2.  That existing sections 1751.83, 3922.01, 3922.03,	1137
3922.05, 3922.06, 3922.07, 3922.08, 3922.09, 3922.10, 3922.14,	1138
3922.15, 3922.16, 3922.17, 3922.20, and 4731.36 and section	1139
3922.13 of the Revised Code are hereby repealed.	1140