State RegulationsOH specificDifficulty 2/5
A member receives written notice that her plan has denied a requested treatment as not medically necessary. Under the framework of ORC 3922.01-.23, what recourse does she have?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Ohio's adverse-benefit-determination provisions (ORC 3922.01-.23) give a member whose claim is denied the right to appeal internally through the plan's review process, with external review available after the internal process. The denial notice must inform the member of these rights; a denial is never simply final on the insurer's word.
Why the other options are wrong
- A) The ORC 3922.01-.23 framework exists precisely to give members appeal rights; the determination is not unreviewable.
- C) The member's first-line remedy is the plan's internal appeal and external review; the framework does not force the member straight to court.
- D) A marketing complaint is not the appeal mechanism; the member must use the plan's appeal and review procedures.
Memory hook
Denied? Appeal inside, then outside — the plan must show you the doorways.