reglab/housing_qa huggingface dataset:
Ohio Rev Code § 3922.11 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3922 | External Review|Section 3922.11 | Review by Superintendent of Insurance.

Effective: January 1, 2021|Latest Legislation:  House Bill 339 - 133rd General Assembly|(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.
Ohio Rev Code § 3922.12 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3922 | External Review|Section 3922.12 | Effect of Decision.

Effective: December 26, 2011|Latest Legislation:  House Bill 218 - 129th General Assembly|(A) An external review decision is binding on the health plan issuer except to the extent the health plan issuer has other remedies available under applicable state law, or unless the superintendent of insurance determines that, due to the facts and circumstances of an external review, a second external review is required. (B) An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or state law, or unless the superintendent determines that, due to the facts and circumstances of an external review, a second external review is required.(C) A covered person may not file a subsequent request for external review involving the same adverse benefit determination for which the covered person has already received an external review decision pursuant to this chapter, except in the event that new medical or scientific evidence is submitted to the health plan issuer.
Ohio Rev Code § 3922.13 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3922 | External Review|Section 3922.13 | Accreditation of Independent Review Organizations.

Effective: December 26, 2011|Latest Legislation:  House Bill 218 - 129th General Assembly|The superintendent shall accredit independent review organizations as prescribed by this section. (A) The superintendent shall develop an application form to accredit and renew accreditation of an independent review organization.(B) An independent review organization seeking to be accredited by the superintendent, or to renew its accreditation, shall submit the application form and include with the form all documentation and information necessary for the superintendent to determine if the independent review organization satisfies the minimum qualifications established under section 3922.14 of the Revised Code.(C)(1) Except as provided in division (C)(2) of this section, an independent review organization is eligible for accreditation by the superintendent under this section only if it is accredited by a nationally recognized private accrediting entity that the superintendent has determined has accreditation standards that are equivalent to or exceed the minimum qualifications for independent review organizations under section 3922.14 of the Revised Code.(2) The superintendent may approve independent review organizations that are not accredited by a nationally recognized private accrediting entity, if there are no acceptable nationally recognized private accrediting entities providing independent review organization accreditation.(D) An independent review organization shall apply to renew its accreditation on an annual basis.(E) If the superintendent determines that an independent review organization has lost its accreditation by a nationally recognized private accrediting entity or no longer satisfies the minimum requirements established under section 3922.14 of the Revised Code, the superintendent shall revoke the independent review organization's accreditation and shall remove the independent review organization from the list of independent review organizations approved to conduct external reviews.(F) The superintendent shall maintain and periodically update a list of accredited independent review organizations.
Ohio Rev Code § 3922.15 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3922 | External Review|Section 3922.15 | Qualifications for Clinical Reviewers.

Effective: September 6, 2012|Latest Legislation:  House Bill 341 - 129th General Assembly|All clinical reviewers assigned by an independent review organization to conduct external reviews shall have the same license as the health care provider of the service in question, and shall be physicians or other appropriate health care providers who meet all of the following minimum qualifications: (A) Be an expert in the treatment of the medical condition that is the subject of the external review;(B) Be knowledgeable about the requested health care service through clinical experience, within the last three years, treating patients with the same, or a similar, medical condition, and, in the case of an external review of an experimental or investigational health care service, be an expert, through clinical experience in the last three years, in the treatment of the covered person's condition and have knowledge of the requested health care service;(C) Hold a nonrestricted license in a state of the United States and, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review;(D) Have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a question as to the clinical reviewer's physical, mental, or professional competence or moral character.
Ohio Rev Code § 3922.16 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3922 | External Review|Section 3922.16 | Construction of Chapter; Limitations on Liability.

Effective: September 6, 2012|Latest Legislation:  House Bill 341 - 129th General Assembly|(A) Nothing in this chapter shall be construed to create a cause of action against any of the following: (1) An employer that provides health care benefits to employees through a health plan issuer;(2) A clinical reviewer or independent review organization that participates in an external review under this chapter;(3) A health plan issuer that provides coverage for benefits pursuant to this chapter.(B) An independent review organization and any clinical reviewer an independent review organization uses in conducting an external review under this chapter is not liable in damages in a civil action for injury, death, or loss to person or property and is not subject to professional disciplinary action for making, in good faith, any finding, conclusion, or determination required to complete the external review.(C) This section does not grant immunity from civil liability or professional disciplinary action to an independent review organization or clinical reviewer for an action that is outside the scope of authority granted under this chapter.
Ohio Rev Code § 3922.17 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3922 | External Review|Section 3922.17 | Maintenance of Records; Reports.

Effective: December 26, 2011|Latest Legislation:  House Bill 218 - 129th General Assembly|(A)(1) An independent review organization assigned pursuant to sections 3922.08, 3922.09, or 3922.10 of the Revised Code to conduct an external review shall maintain written records in accordance with the associated rules established by the superintendent, in the aggregate by state, and by the health plan issuer, on all external reviews requested and conducted during a calendar year. Each independent review organization shall submit this information to the superintendent, upon request, in a report in the format specified by the superintendent that shall include, in the aggregate by state and for each health plan issuer, all of the following:(a) The total number of requests for external review;(b) The number of requests for external review resolved and, of those resolved, the number upholding and the number reversing an adverse benefit determination;(c) The average length of time for a resolution;(d) A summary of the types of requested health care services or cases for which an external review was sought;(e) The number of external reviews that were terminated as the result of a reconsideration by the health plan issuer of an adverse benefit determination after the receipt of additional information from the covered person under section 3922.05 of the Revised Code;(f) The costs associated with external reviews, including the amounts charged by the independent review organization to conduct the reviews;(g) The medical specialty, or the type, of clinical reviewer used to conduct each external review, as related to the specific medical condition of the covered person;(h) Any other information the superintendent may request or require.(2) The independent review organization shall retain the written records required under division (A)(1) of this section for at least three years.(B) A health plan issuer shall maintain written records on all requests made for an external review under this chapter and shall provide all such information as required by any associated rules, policies, or procedures adopted by the superintendent of insurance. A health plan issuer shall maintain written records on all requests for external review for at least three years.(C) The superintendent shall compile and annually publish the information collected under this section and report the information to the governor, the speaker and minority leader of the house of representatives, the president and minority leader of the senate, and the chairs and ranking minority members of the house and senate committees with jurisdiction over health and insurance issues.
Ohio Rev Code § 3922.18 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3922 | External Review|Section 3922.18 | Payment of Costs.

Effective: December 26, 2011|Latest Legislation:  House Bill 218 - 129th General Assembly|The health plan issuer against which a request for a standard external review or an expedited external review is filed shall pay the cost of the external review, including the cost of any external review that is required at the direction of the superintendent.If the superintendent determines that, due to the facts and circumstances of an external review, a second external review is required, the health plan issuer shall pay the costs of the second review.
Ohio Rev Code § 3922.20 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3922 | External Review|Section 3922.20 | Admissibility of Written Decision or Medicare Reimbursement Standards.

Effective: December 26, 2011|Latest Legislation:  House Bill 218 - 129th General Assembly|Consistent with the Rules of Evidence, a written decision or opinion prepared by an independent review organization under this chapter shall be admissible in any civil action related to the coverage decision that was the subject of the decision or opinion. The independent review organization's decision or opinion shall be presumed to be a scientifically valid and accurate description of the state of medical knowledge at the time it was written. Consistent with the Rules of Evidence, any party to a civil action related to a plan's decision involving an investigational or experimental drug, device, or treatment may introduce into evidence any applicable medicare reimbursement standards established under Title XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 U.S.C.A. 301, as amended.
Ohio Rev Code § 3922.21 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3922 | External Review|Section 3922.21 | Confidentiality.

Effective: December 26, 2011|Latest Legislation:  House Bill 218 - 129th General Assembly|(A) When a record containing information pertaining to the medical history, diagnosis, prognosis, or medical condition of a covered person is provided to the superintendent of insurance for any reason under this chapter or sections 1751.77 to 1751.87 of the Revised Code, regardless of the source, the superintendent shall maintain the confidentiality of the record. The record in the superintendent's possession is not a public record under section 149.43 of the Revised Code, except to the extent that information from the record is used in preparing reports under section 3922.17 of the Revised Code. (B) Notwithstanding division (A) of this section, the superintendent may share a record that is the subject of this section in connection with the investigation or prosecution of any illegal or criminal activity with the chief deputy rehabilitator, the chief deputy liquidator, other deputy rehabilitators and liquidators, and any other person employed by, or acting on behalf of, the superintendent pursuant to Chapter 3901. or 3903. of the Revised Code, with other local, state, federal, and international regulatory and law enforcement agencies, with local, state, and federal prosecutors, and with the national association of insurance commissioners and its affiliates and subsidiaries, provided that the recipient agrees to maintain the confidential or privileged status of the confidential or privileged record and has authority to do so.(C) Nothing in this section shall prohibit the superintendent from receiving records in accordance with section 3901.045 of the Revised Code.(D) The superintendent may enter into agreements governing the sharing and use of records consistent with the requirements of this section.(E) No waiver of any applicable privilege or claim of confidentiality in the records that are the subject of this section shall occur as a result of sharing or receiving records as authorized in divisions (B) and (C) of this section.
Ohio Rev Code § 3922.22 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3922 | External Review|Section 3922.22 | Adoption of Rules.

Effective: December 26, 2011|Latest Legislation:  House Bill 218 - 129th General Assembly|The superintendent may adopt rules under Chapter 119. of the Revised Code to carry out the purposes of this chapter and shall prescribe forms relating to notices, appeals, and requests for external review under this chapter.
Ohio Rev Code § 3923.01 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3923 | Sickness and Accident Insurance|Section 3923.01 | Policy of Sickness and Accident Insurance Defined.

Effective: November 24, 1995|Latest Legislation:  Senate Bill 150 - 121st General Assembly|As used in this chapter, "policy of sickness and accident insurance" includes any policy, contract, or certificate of insurance against loss or expense resulting from the sickness of the insured, or from the bodily injury or death of the insured by accident, or both, that is delivered, issued for delivery, renewed, or used in this state on or after the date occurring six months after the effective date of this amendment.
Ohio Rev Code § 3923.011 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3923 | Sickness and Accident Insurance|Section 3923.011 | Sickness and Accident Insurance Definitions.

Effective: January 9, 1961|Latest Legislation:  House Bill 1 - 104th General Assembly|As used in any policy of sickness and accident insurance delivered, issued for delivery, or used in this state, unless otherwise provided in the policy or in an indorsement thereon or in a rider attached thereto:(A) "Total disability" means inability to perform the duties of any gainful occupation for which the insured is reasonably fitted by training, experience, and accomplishment.(B) "Confinement to house" includes the activities of a convalescent not able to be gainfully employed.(C) "Accidental death" means death by accident exclusively and independently of all other causes.
Ohio Rev Code § 3923.02 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3923 | Sickness and Accident Insurance|Section 3923.02 | Form of Policy Filed With Superintendent.

Effective: July 1, 1955|Latest Legislation:  House Bill 881 - 101st General Assembly|No certificate shall be furnished by any insurer in connection with, or pursuant to any provision of, any group sickness and accident insurance policy delivered, issued for delivery, or used in this state, and no policy of sickness and accident insurance shall be delivered, issued for delivery, or used in this state, nor shall any indorsement, rider, or application which becomes or which is designed to become a part of any such policy or certificate be delivered, issued for delivery, or used in this state, until a copy of the form of such policy, certificate, indorsement, rider, or application and of the premium rates and of the classification of risks pertaining thereto has been filed with the superintendent of insurance. No such policy, certificate, indorsement, rider or application shall be delivered, issued for delivery, or used until the expiration of thirty days after the form of such policy, certificate, indorsement, rider, or application has been filed with the superintendent, unless he has previously given to the insurer his written approval thereto. If the superintendent finds that any such form of policy, certificate, indorsement, rider, or application which has been filed with him by an insurer contains any provision which is contrary to the law of this state, or contains inconsistent provisions, or contains any question, provision, title, heading, backing, or other indication of its contents, which is ambiguous, misleading, or deceptive, or likely to mislead or deceive the policyholder, certificate holder or applicant, he shall give written notice of his finding to the insurer which has filed such form, and thereafter no insurer which has filed such form shall deliver, issue for delivery, or use such form in this state.After the expiration of thirty days from the filing of any such form, or at any time after the superintendent has given written approval thereof, the superintendent may, after a hearing of which at least twenty days' written notice has been given to the insurer issuing such form, withdraw approval on any ground stated in this section. Such disapproval shall be effected by written order of the superintendent which shall state the ground for disapproval and the date, not less than thirty days after such hearing, when the withdrawal of approval shall become effective. After the date when the withdrawal of approval of any such form becomes effective, such form shall not be delivered, issued for delivery, or used in this state. The form of any certificate furnished by any insurer to a resident of this state in connection with, or pursuant to any provisions of, any group sickness and accident insurance policy which policy is not delivered, issued for delivery, or used in this state but which insures residents of this state shall, upon request of the superintendent, be filed with the superintendent.
Ohio Rev Code § 3923.03 (2021)
2021 Ohio Revised Code|Title 39 | Insurance|Chapter 3923 | Sickness and Accident Insurance|Section 3923.03 | Necessary Provisions.

Effective: October 1, 1953|Latest Legislation:  House Bill 1 - 100th General Assembly|No policy of sickness and accident insurance shall be delivered, issued for delivery, or used in this state unless all the following requirements are complied with:(A) The entire money and other considerations therefor are expressed therein.(B) The time at which insurance takes effect and terminates is expressed therein.(C) It purports to insure only one person, except that a policy may be issued to the head of a family, who for this purpose may be the husband or the wife and who is considered the policyholder, covering any two or more members of any one family, including husband, wife, dependent children, any children under the age of nineteen, and other dependents living with the family.(D) Every printed portion of the text matter and of any indorsements or attached papers shall be printed in uniform type of which the face shall be not less than ten point, the "text" to include all printed matter except the name and address of the insurer, name and title of the policy, captions, subcaptions, and form number. The superintendent of insurance shall not disapprove any such policy on the ground that every printed portion of its text matter or of any indorsement or attached paper is not printed in uniform type if it is shown that the type used is required to conform to the laws of another state in which the insurer is licensed.(E) The exceptions and reductions of indemnity are adequately captioned and clearly set forth in the policy.(F) Every such policy, including riders and indorsements, shall be identified by a form number in the lower left-hand corner of its first page.