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Library: Policy

317:2-3-6. External medical review and clinical expertise

Revised 7-1-23

(a) External medical review. The OHCA will not offer an external medical review for the purposes of grievances or appeals.

(b) Clinical expertise standards. Individuals making the decision for a grievance or appeal regarding an adverse benefit determination will be unbiased with appropriate clinical expertise in treating the member's condition or disease.

(1) Medical review staff of the CE and DBM will be licensed or credentialed health care clinicians with relevant clinical training and/or experience.

(2) All CE and DBM will use medical review staff for such appeals and shall not use any automated claim review software or other automated functionality for such appeals.

(3) Bias is deemed to exist if an individual making a decision on a grievance or appeal was involved in, or a subordinate of any individual involved in, any previous level of review or decision regarding the subject matter of the grievance or appeal.

(4) Clinical expertise is deemed necessary for decisions makers whenever:

(A) The denial is based on a lack of medical necessity;

(B) The grievance is regarding a denial of an expedited resolution an appeal; and

(C) The grievance or appeal involves clinical issues.

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