Welcome to the Ohio Department of Insurance

Skip Navigation

Please Note: You are viewing the non-styled version of Ohio Department of Insurance. Either your browser does not support Cascading Style Sheets (CSS) or it is disabled. We suggest upgrading your browser to the latest version of your favorite Internet browser.

Ohio.gov
Ohio Internal Appeal and External Review Model Notices

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 in both Microsoft Word (.doc) and Portable Document Format (.pdf):

 

  • Notice of Adverse Benefit Determination

 Microsoft Word Document (.doc)                     Portable Document Format (.pdf)

 

  • Internal Appeal Request Form

 Microsoft Word Document (.doc)                     Portable Document Format (.pdf)

 

  • Notice of Final Adverse Benefit Determination

 Microsoft Word Document (.doc)                     Portable Document Format (.pdf)

 

  • External Review Request Form

 Microsoft Word Document (.doc)                     Portable Document Format (.pdf)

 

  • Consumer External Review Procedures Summary

 Microsoft Word Document (.doc)                     Portable Document Format (.pdf)

  • Treating Physician Certification for Internal Appeal and/or External Review

 Microsoft Word Document (.doc)                    Portable Document Format (.pdf)

 

  • Treating Physician Certification for Experimental/Investigational Adverse Benefit Determinations

 Microsoft Word Document (.doc)                    Portable Document Format (.pdf)

 

  • Notice of Denial of External Review Request

 Microsoft Word Document (.doc)                     Portable Document Format (.pdf)

 

  • Request for Appeal of External Review Request Denial

 Microsoft Word Document (.doc)                     Portable Document Format (.pdf)

 

  • External Review Request Confirmation Notices
    • Expedited IRO Review

 Microsoft Word Document (.doc)                     Portable Document Format (.pdf)

 

  • Non-Expedited (Standard) IRO Review

 Microsoft Word Document (.doc)                     Portable Document Format (.pdf)

 

  • ODI Contractual Review

 Microsoft Word Document (.doc)                     Portable Document Format (.pdf)


The State of Ohio is an Equal Opportunity Employer

Ohio Department of Insurance
50 W. Town Street, Third Floor - Suite 300
Columbus, Ohio  43215
|
|
|
John Kasich, Governor | Jillian Froment, Director
General Info: 614-644-2658 | Consumer Hotline: 800-686-1526
Fraud Hotline: 800-686-1527 | OSHIIP Hotline: 800-686-1578