Current through all regulations passed and filed through September 16, 2024
(A)
Purpose
The purpose of this rule is to
implement sections
3902.50
to
3902.54
of the Revised Code.
(B)
Authority
This rule is promulgated pursuant to
the authority vested in the superintendent under sections
3902.50
to
3902.54
of the Revised Code.
(C)
Scope
This rule applies to all unanticipated
out-of-network care as defined in section
3902.50
of the Revised Code.
(D)
No private cause
of action
Nothing herein shall be construed to
create or imply a private cause of action for a violation of this
rule.
(E)
Definitions
As used in this rule:
(1)
"Ambulance" has
the same meaning as in section
4765.01
of the Revised Code.
(2)
"Clinical laboratory services" has the same meaning as
in section
4731.65
of the Revised Code.
(3)
"Cost sharing" means the cost to a covered person under
a health benefit plan according to any copayment, coinsurance, deductible, or
other out-of-pocket expense requirement.
(4)
"Covered person,"
"health benefit plan," "health care services," and "health plan issuer" have
the same meanings as in section
3922.01 of the
Revised Code.
(5)
"Emergency facility" has the same meaning as in section
3701.74
of the Revised Code.
(6)
"Emergency services" means all of the following as
described in
42
U.S.C. 1395dd:
(a)
Medical screening
examinations undertaken to determine whether an emergency medical condition
exists;
(b)
Treatment necessary to stabilize an emergency medical
condition; and
(c)
Appropriate transfers undertaken prior to an emergency
medical condition being stabilized.
(7)
"Unanticipated
out-of-network care" means health care services, including clinical laboratory
services, that are covered under a health benefit plan and that are provided by
an out-of- network provider when either of the following conditions
applies:
(a)
The covered person did not have the ability to request such
services from an in-network provider.
Clinical laboratory services provided
by an out-of-network provider, but that are ordered by an in-network provider,
shall be considered to have met the condition prescribed in paragraph (E)(7)(a)
of this rule unless the provider rendering the laboratory services discloses
its network status in writing to the covered person before the services are
provided.
(b)
The services provided were emergency
services.
(F)
Health plan
issuer reimbursement for unanticipated out of network care
(1)
Use of geographic
region in calculation of health plan issuer reimbursement amount. For purposes
of determining the amount negotiated with in-network providers, facilities,
emergency facilities, or ambulances for the service in question in a geographic
region under a health benefit plan, a health plan issuer shall use the
geographic region in which the service was performed. The geographic regions in
this state shall consist of one region for each metropolitan statistical area,
as described by the U.S. office of management and budget and published by the
U.S. census bureau, and one region consisting of all other portions of the
state.
(2)
Application of prompt pay requirements to health plan
issuer reimbursement. A health plan issuer shall send an initial claim payment
as its intended reimbursement required by division (B)(1) of section
3902.51
of the Revised Code to the provider, facility, emergency facility, or ambulance
in compliance with sections
3901.38
to
3901.3814
of the Revised Code.
(3)
A health plan issuer shall pay all reimbursement
amounts for unanticipated out-ofnetwork care directly to the provider,
facility, emergency facility, or ambulance in accordance with division (B)(1)
of section
3902.51
of the Revised Code.
Any amounts paid by a health plan
issuer for unanticipated out-of-network care shall include remittance advice
remark codes to identify that the payment is made pursuant to division (B)(1)
of section
3902.51
of the Revised Code.
(4)
In a request for
reimbursement of a health care service subject to this rule, the provider,
facility, emergency facility, or ambulance shall include the proper billing
code for the service for which reimbursement is requested.
Such request for reimbursement shall
also include:
(a)
Sufficient information for the health plan issuer to
identify the facility where a health care service was provided;
(b)
Sufficient
information for the health plan issuer to identify a request for reimbursement
where the provider, facility, emergency facility, or ambulance, has met the
good faith estimate and affirmative consent conditions contained in division
(E)(1) of section
3902.51
of the Revised Code; and
(G)
Health plan
issuer identification cards
Identification cards provided to a
covered person, if any, must clearly and conspicuously denote the letters "ODI"
prominently displayed on the front of the card or document.
If a health plan issuer permits
providers to access a covered person's eligibility or coverage information
through an electronic system, the system must prominently display a statement
that the covered person's health benefit plan is subject to sections
3902.50
to
3902.54
of the Revised Code.
(H)
Covered person
cost sharing amount
(1)
A health plan issuer shall not require cost sharing for
any service described in division (A) of section
3902.51
of the Revised Code from the covered person at a rate higher than if the
services were provided in-network.
(2)
For purposes of
this rule, the in-network rate for cost sharing shall be a dollar amount
calculated at the time the health plan issuer calculates the initial
reimbursement amount required in division (B)(1) of section
3902.51
of the Revised Code.
(3)
The covered person's cost sharing amount shall not be
adjusted due to the outcome of any subsequent negotiation or arbitration
between the health plan issuer and provider, facility, emergency facility, or
ambulance.
(I)
Negotiation in lieu of accepting issuer
reimbursement
(1)
The provider, facility, emergency facility, or
ambulance shall, within thirty business days of receiving reimbursement for
unanticipated out of network care, notify the health plan issuer that the
provider, facility, emergency facility or ambulance chooses to negotiate
reimbursement.
(2)
Failure to notify the health plan issuer of an intent
to negotiate within the timeframe set forth in paragraph (I)(1) of this rule
shall be considered acceptance of the health plan issuer's
reimbursement.
(3)
If the provider, facility, emergency facility, or
ambulance timely notifies the health plan issuer of its intent to negotiate in
accordance with the requirements of this rule, the health plan issuer shall,
upon request, disclose to the provider, facility, emergency facility, or
ambulance each reimbursement amount the health plan issuer calculated for the
claim pursuant to division (B)(1) of section
3902.51
of the Revised Code.
(4)
If, during a period of negotiation, the health plan
issuer and the provider, facility, emergency facility or ambulance agree on a
new reimbursement rate for a claim, then the health plan issuer shall send
payment directly to the provider, facility, emergency facility or ambulance
within thirty calendar days.
(5)
If, during a
period of negotiation, the health plan issuer and the provider, facility,
emergency facility or ambulance agree on a reimbursement rate for a claim, then
that claim is not eligible for arbitration.
(6)
If negotiation
pursuant to paragraph (I) of this rule has not successfully concluded within
thirty business days, or if both parties agree that they are at an impasse, a
provider, facility, emergency facility, or ambulance may choose to arbitrate
that claim so long as the claim meets the eligibility requirements of division
(A)(1) of section
3902.52
of the Revised Code.
(J)
Arbitration
(1)
Requests for
arbitration:
(a)
A provider, facility, emergency facility, or ambulance
may request arbitration to determine the reimbursement for a claim or claims
that are eligible for arbitration pursuant to section
3902.52
of the Revised Code.
(b)
Requests for arbitration shall be submitted to the
superintendent electronically on a form or through a system prescribed by the
superintendent.
(c)
Upon receipt of a complete request for arbitration, the
superintendent shall notify the contracted arbitration entity of the request
for arbitration within four business days.
(d)
The contracted
arbitration entity shall assign an arbitrator within ten business days and
shall provide notice to the health plan issuer and provider, facility,
emergency facility, or ambulance.
(e)
Each party shall
submit its final offer and supporting evidence, if any, to the arbitrator
within ten business days after an arbitrator is assigned.
The final offer submitted to the
arbitrator by either party shall be an amount the submitting party considers a
fair reimbursement rate.
(f)
The arbitrator
shall consider the evidence submitted by the parties and render a decision
within thirty business days.
(g)
If the arbitrator
determines that the final offer submitted by the provider, facility, emergency
facility, or ambulance best reflects a fair reimbursement rate, the health plan
issuer shall pay the difference, if any, between the reimbursement rate
selected by the arbitrator and the initial payment made by the health plan
issuer pursuant to division (B)(1) of section
3902.51
of the Revised Code.
The health plan issuer shall pay the
reimbursement directly to the provider, facility, emergency facility, or
ambulance within thirty calendar days of the arbitrator's
decision.
(h)
If the arbitrator determines that the final offer
submitted by the health plan issuer best reflects a fair reimbursement rate,
the provider, facility, emergency facility, or ambulance shall pay the health
plan issuer the difference, if any, between the health plan issuer's
reimbursement rate selected by the arbitrator and the initial payment made by
the health plan issuer pursuant to division (B)(1) of section
3902.51
of the Revised Code.
The provider, facility, emergency
facility, or ambulance, shall pay the reimbursement directly to the health plan
issuer within thirty calendar days of the arbitrator's decision.
(2)
Claims bundling.
(a)
For purposes of
bundling claims for arbitration, provider includes a practice of providers to
the extent such providers contract with health plan issuers as a single
practice.
(b)
If negotiation pursuant to division (B)(2) of section
3902.51
of the Revised Code is unsuccessful, a provider, facility, emergency facility,
or ambulance may choose to arbitrate that claim as a bundle of up to fifteen
claims at a later date, so long as all of the claims meet the requirements of
division (A)(1) of section
3902.52
of the Revised Code.
(3)
Costs.
(a)
The arbitration
entity shall perform each arbitration on a flat fee basis.
(b)
There shall be no
additional costs for a single arbitration of up to fifteen bundled
claims.
(c)
The non-prevailing party shall pay seventy per cent of
the arbitrator's fees, and the prevailing party shall pay thirty per
cent.
(i)
For
purposes of this rule, the non-prevailing party shall be the party whose final
offer was not selected by the arbitrator. If multiple claims are bundled for a
single arbitration, the non-prevailing party shall be the party whose final
offer for each claim was selected fewer times by the
arbitrator.
(ii)
For purposes of this rule, the prevailing party shall
be the party whose final offer was selected by the arbitrator. If multiple
claims are bundled for a single arbitration, the prevailing party shall be the
party whose final offer for each claim was selected more times by the
arbitrator.
(d)
In the event that multiple claims are bundled in a
single arbitration and the arbitrator selects a final offer from each party the
same number of times, then there is no prevailing party and each party shall
pay fifty per cent of the arbitrator's fees.
(e)
Each party shall
bear their own costs for all other expenses related to
arbitration.
(4)
Submission of evidence for purposes of
arbitration.
(a)
Each party may submit evidence relating to the factors
contained in division (C) of section
3902.52
of the Revised Code except:
(i)
No party may submit billed charges as
evidence.
(ii)
No party may submit public payer rates such as medicare
or medicaid reimbursement amounts as evidence.
(b)
Evidence must be
in a form that can be verified and authenticated.
(c)
Evidence must be
in a format compatible with the secure portal utilized by the arbitration
entity.
(K)
Severability
If any paragraph, term or provision of
this rule is adjudged invalid for any reason, the judgment shall not affect,
impair or invalidate any other paragraph, term or provision of this rule, but
the remaining paragraphs, terms and provisions shall be and continue in full
force and effect.
