State RegulationsOH specificDifficulty 2/5
A member of a health insuring corporation in Cleveland is scheduled for elective knee surgery, and the contract requires approval before the procedure is performed. Under ORC 1751.72, what does this prior-authorization requirement accomplish?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under ORC 1751.72, HIC contracts must follow utilization-review and prior-authorization procedures under which a planned service is reviewed and approved before it is rendered. The member confirms coverage in advance rather than discovering a coverage problem after the surgery, and the process is a defined review procedure rather than an automatic denial.
Why the other options are wrong
- A) Prior authorization is a review-and-approval process under ORC 1751.72, not an automatic denial rule.
- C) The plan reviews the service under its utilization-review procedures; the provider does not simply bill the member without review.
- D) The employer has no role in prior-authorization decisions; the review runs between the plan and the provider under ORC 1751.72.
Memory hook
Prior authorization = permission before the procedure, not a bill after.