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State guide

Ohio

Pick the kind of plan you have to see who to call first. Ohio can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

The short version for Ohio

In Ohio you ask your own health plan to start the external review, and the Ohio Department of Insurance then randomly assigns an independent reviewer. Unusually, Ohio also reviews contract-based denials (not only medical ones): the Department of Insurance itself decides those. Ohio has no separate consumer assistance program, so the Department's consumer hotline is the main source of free help.

At a glance: independent review for plans Ohio regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
Ohio Department of Insurance · 800-686-1526
Independent review
A state process (External review)
Deadline to request it
180 days from the date of the final adverse benefit determination (the plan's final denial)
Decision time
30 days from when the health plan receives a complete request; fast track: 72 hours from when the health plan receives the request

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

Look at the front of your insurance card. Plans that fall under Ohio's surprise billing rules must show the letters "ODI" (Ohio Department of Insurance) prominently on the front of the card. The Department says it cannot address problems with an employer's self-funded health plan unless a company licensed by the Department is involved.

  • Ohio Department of Insurance

    Health insurance sold in Ohio to individuals and to employers that buy a policy from an insurance company or health maintenance organization (HMO). It cannot address an employer's self-funded plan unless the plan involves an insurer, HMO or administrator licensed by the Department.

    Phone: 800-686-1526. File a complaint online

Independent (external) review

Process
A state process. Run by The Ohio Department of Insurance randomly assigns an accredited independent review organization for denials involving medical judgment or experimental treatment; the Department itself reviews denials based only on the contract.
Where you file
insurer
How
Send a written request (mail, email or fax) to your health plan using the instructions in your final denial letter. If your situation is urgent you can ask by phone. If the plan says your case is not eligible, you can appeal that to the Ohio Department of Insurance at 800-686-1526.
Which denials qualify
Denials that involve medical judgment or medical information, and denials of treatment as experimental or investigational, go to an independent review organization. Denials based on a contract issue with no medical judgment are reviewed by the Ohio Department of Insurance. A denial is eligible regardless of the cost of the service.
Appeal to the plan first?
Yes, except when the plan agrees to waive it, you did not get a written internal appeal decision in the required time, the plan failed to meet all the internal appeal requirements, or you request an expedited external review at the same time as an expedited internal appeal.

Official page

General rules and what to send: how external review works, how to request it.

Free help in Ohio

Medicare and Medicaid in Ohio

Medicare counseling
Ohio Senior Health Insurance Information Program (OSHIIP) · 800-686-1578 . Free help with Medicare appeals.
Medicaid agency
Ohio Department of Medicaid (state hearings are run by the Ohio Department of Job and Family Services, Bureau of State Hearings)
Fair hearing deadline
Your request must be received within 90 days of the date the notice was mailed. Your notice states the deadline that applies to you.
Good to know
If a managed care plan denied, reduced or stopped a service, you must appeal to the plan first; the state rule then gives 90 calendar days from the plan's appeal decision to ask for a state hearing. If your hearing request is received within 15 days of the notice mail date, benefits are not stopped or lowered until the hearing decision. Ohio Medicaid Consumer Hotline: 1-800-324-8680.

Medicaid appeals page How Medicaid appeals work

State laws that can help

  • Step therapy. Plans that use step therapy must give prescribers a clear way to request an exemption, decide within 48 hours for urgent care or 10 calendar days otherwise, and a request not decided on time is treated as approved.

    Ohio Revised Code 3901.832

  • Prior authorization. Insurers must answer prior authorization requests within 48 hours for urgent care or 10 calendar days otherwise, give the specific reason for a denial, and generally cannot take back an approval after the service was provided as approved.

    Ohio Revised Code 3923.041

  • Surprise billing. For emergency care and unanticipated out-of-network care, you owe only your in-network cost sharing and the provider cannot bill you for the balance.

    Ohio Revised Code 3902.50 to 3902.54

  • External review. Every denial is eligible for internal appeal or external review regardless of cost, and the Superintendent of Insurance can overrule a plan that says a request is not eligible.

    Ohio Revised Code 3922.02 and 3922.05

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Health Coverage and External Review Appeals Process (Ohio Department of Insurance)
  2. Health Insurance Guide (Ohio Department of Insurance)
  3. External Review Procedures Summary (Ohio Department of Insurance)
  4. Ohio Revised Code 3922.02
  5. Consumer Complaint Information (Ohio Department of Insurance)
  6. Surprise Billing FAQs (Ohio Department of Insurance)
  7. Ask for a State Hearing (Ohio Department of Job and Family Services)
  8. Ohio Administrative Code 5160-26-08.4
  9. Ohio Health Insurance Consumer Help (Centers for Medicare & Medicaid Services)
  10. State External Appeals Review Processes (Centers for Medicare & Medicaid Services)
Not confirmed (6)
  • The cost of independent review. no Ohio Department of Insurance page or statute section read states whether the consumer pays anything; left null
  • The independent review request form. no consumer request form found; requests go to the health plan
  • The official independent review page. the Health Insurance Guide page holds the detailed questions and answers but returned an error to one fetch tool; the toolkit page is linked instead
  • Not confirmed. externalReview.decisionsDatabaseUrl and statisticsNote — no published decisions or overturn rate found
  • Notes on Medicaid appeals. Disability Rights Ohio says 120 days to request a state hearing after a managed care appeal decision, but Ohio Administrative Code 5160-26-08.4 says 90 calendar days; the shorter figure is shown
  • Free consumer help programs. the federal directory lists no Consumer Assistance Program for Ohio

Sources last checked . Found a mistake? Report it.