State RegulationsOH specificDifficulty 3/5
A plan issues an adverse benefit determination on a member's claim. To comply with the consumer-protection framework of ORC 3922.01-.23, what should the determination notice convey?
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Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
The adverse-benefit-determination framework at ORC 3922.01-.23 is built on informed review: the notice must give the specific reason for the denial, the plan provisions the decision rests on, and a description of the member's appeal and review rights. A notice that omits these elements cannot start the appeal process fairly, and the member cannot evaluate whether to challenge the decision.
Why the other options are wrong
- A) The reason must be disclosed; a bare decision with concealed reasons defeats the framework's purpose.
- B) The effective date alone tells the member nothing about why benefits were cut or how to contest it.
- C) The determination is subject to internal appeal and external review, so a final-only statement misdescribes the member's rights.
Memory hook
Notice must say why, on what rule, and how to fight it.