To ensure that Ohio consumers receive all information necessary to make an informed decision regarding an adverse benefit determination by their health plan issuer, the Ohio Department of Insurance developed model notices and forms for the internal appeals and external review processes. Health plan issuers may use the model notices and forms provided below verbatim or design their own substantially similar versions.
The model notices and forms represent minimum standards required under Ohio Revised Code Chapter 3922. Any substantially similar version must include all information provided in the model notice or form. Also, please carefully review Ohio Revised Code Chapter 3922 regarding specific requirements for provision of notice.
Each model notice is provided below.
- Notice of Adverse Benefit Determination
- Internal Appeal Request Form
- Notice of Final Adverse Benefit Determination
- External Review Request Form
- Consumer External Review Procedures Summary
- Treating Physician Certification for Internal Appeal and/or External Review
- Treating Physician Certification for Experimental/Investigational Adverse Benefit Determinations
- Notice of Denial of External Review Request
- Request for Appeal of External Review Request Denial
- External Review Request Confirmation Notices