180 days, and a reviewer drawn by the Superintendent: Ohio's two tracks

The appeal is a conversation between peers

Ohio frames the prior-authorization appeal as a direct exchange: it is to be between the practitioner who requested the service and a clinical peer. A clinical peer is a physician where the evaluation concerns the clinical appropriateness of services provided by a physician; where the service came from a non-physician, it is either a physician or a provider holding the same licence.

• Urgent care: the appeal is considered within 48 hours of receipt.
• Everything else: within ten calendar days of receipt.

Two tracks: the IRO and the Superintendent

Ohio does not send every external review to the same place. When the denial rests on medical judgment — medical necessity, appropriateness, the setting of care, an experimental or investigational determination — an accredited independent review organization decides it. When the denial rests on a contract question, such as whether the service is covered at all, cost-sharing, network status or eligibility, ORC 3922.11 sends the case to the Superintendent of Insurance, and the Department decides it directly.

Knowing which track a denial belongs on before filing matters, because the record that persuades a physician reviewer is not the record that answers a coverage-language dispute. Read the plan's stated reason for the final denial and build to that.

• Clinical or medical-judgment denial: an accredited IRO reviews it under ORC 3922.05.
• Contractual denial (covered service, cost-sharing, network, eligibility): the Superintendent decides under ORC 3922.11.
• Emergency-services denials get a second look: after an IRO has ruled, ORC 3922.05(C) sends the question to the Superintendent under the prudent layperson standard.
• The internal appeal normally has to be exhausted first (ORC 3922.04), subject to the statute's waiver exceptions.
• The decision binds both sides, and a second request on the same denial is barred unless new medical or scientific evidence is presented (ORC 3922.12).

180 days — and who is allowed to file

ORC 3922.02(B) gives the covered person 180 days from the date of the final adverse benefit determination to request external review in writing, and electronic submission counts as writing. That is a full six months, materially longer than the federal four-month floor, and it has stood unchanged since the statute took effect. An expedited request may be made orally instead of in writing.

There is no separate, shorter provider window in Ohio — but there is a consent requirement. A practice files inside the same 180 days as the patient's authorized representative under ORC 3922.01(C), which normally means the patient's express written consent has to be in hand. A treating professional may act without that consent only when the patient is unable to give it. Getting the signed authorization at the same time you calendar the deadline avoids losing weeks to paperwork later.

How to file

1. 1

   Finish the internal appeal

   ORC 3922.04 normally requires the plan's internal appeal to be exhausted before external review, with limited statutory exceptions.

2. 2

   Send the written request to the health plan issuer

   This is the step most often misfiled. The request goes to the insurer, not to the Department. ODI publishes a Model External Review Request Form, plus a Treating Physician Certification form used for expedited and experimental or investigational cases.

3. 3

   The insurer screens it and submits it to ODI

   The issuer checks the request for completeness, then enters it into the Department's external review system, which handles reviewer assignment. ODI's online system is credentialed for insurers, IROs and third-party administrators — it is not a submission channel for patients or practices.

4. 4

   Send your evidence directly to the reviewer

   After the completeness notice, the covered person has 10 business days to send additional information straight to the IRO (ORC 3922.05(D)(1)(b)). Records that arrive later may not be considered.

5. 5

   If the insurer calls the denial ineligible, take that to ODI

   The Department publishes a Model Request for Appeal of External Review Request Denial, and ORC 3922.05(E)(3) lets ODI declare the request eligible regardless of what the plan decided. Questions go to [email protected] or 614-644-0188 (ODI Consumer Affairs, 50 West Town Street, Suite 300, Columbus, OH 43215).

Who picks the reviewer, and the clocks

Random assignment is written into the statute, not left to policy. Under ORC 3922.05(F), once external review is granted the Superintendent assigns an IRO from the accredited list maintained under ORC 3922.13, and the assignment must be done on a random basis among reviewers qualified for that type of service. ORC 3922.14 bars assigning an IRO with a conflict of interest, and a reviewer that declines on conflict grounds triggers automatic reassignment. The carrier has no say in who reads the file.

• Standard review: written decision within 30 days of the insurer's receipt of the request (ORC 3922.05(H)(1)). ODI measured an average of 20 days in 2019.
• Expedited review: no more than 72 hours (ORC 3922.05(H)(1), 3922.09(E)). ODI measured an average of 41 hours in 2019.
• Expedited requires a treating physician to certify jeopardy to life or health, or to the ability to regain maximum function, or an unresolved emergency admission.
• ORC 3922.09(I) bars expedited review outright for retrospective, post-service final denials — so a billing-side appeal on a service already rendered runs on the 30-day clock, however urgent it feels.

What it costs: nothing to you

• ORC 3922.18 puts the entire cost of a standard or expedited external review on the health plan issuer, including any second review the Superintendent orders.
• ODI reported the 2019 statewide IRO bill at roughly $425,085 — about $736 per standard review and $698 per expedited review, all borne by the plans.
• There is no minimum dollar threshold to qualify (ORC 3922.02(C)), so a small-balance denial is as eligible as a five-figure one.

What Ohio's published numbers show

The figures below come from ODI's Annual Health Claims External Review Report for 2019, the most recent edition available from an official Ohio source. In that year 583 cases went to independent review, covering more than $8.9 million in disputed benefits. Reviewers reversed the denial in 35% of them, recovering over $3,762,000 — about 42% of the dollars actually reviewed.

• Standard track: 477 reviews, 160 reversals (34%).
• Expedited track: 106 reviews, 45 reversals (42%).
• The Department's own contractual reviews ran separately: 174 completed, 64 reversed, recovering close to $239,000.
• Reversed dollars concentrated hard by category — drug therapy over $1,978,000, surgery $527,000, durable medical equipment $281,000. Those three were roughly 74% of everything recovered.
• Since Ohio's external review law took effect in 1999: 8,440 cases and more than $31.4 million recovered.

For Ohio providers and billers

Ohio's prior-authorization statute, ORC 3923.041, is specific enough to cite in an appeal. An electronically submitted prior authorization must be answered within 48 hours for urgent care and 10 calendar days otherwise. A denial must state a specific reason, and an incomplete request must come back with an itemized list of what is missing. Plans must publish their PA requirements and required documentation on the provider portal and give 30 days' notice before a new requirement takes effect. Fax and proprietary drug portals do not count as secure electronic transmission, which matters when a plan claims a request was never received.

Two provisions of that statute reach the billing side directly. A drug prior authorization for a chronic condition holds for 12 months, and a plan may not retroactively deny an authorization it already approved when eligibility, the patient's condition and the claim all match what was authorized. The statute also mandates a streamlined PA appeal, decided in 48 hours when urgent or 10 calendar days otherwise, conducted peer-to-peer between the requesting practitioner and a clinical peer — and that appeal feeds directly into Chapter 3922 external review. A pattern of violations is an unfair and deceptive practice under ORC 3901.19 to 3901.26.

Step therapy carries the sharpest deadline in Ohio law. Under ORC 3901.832, added by SB 265 and effective 04/05/2019, a plan must grant or deny an override request within 48 hours when urgent or 10 calendar days otherwise, and 3901.832(A)(6) deems the exemption granted if the plan misses that deadline. Record the date and time you submitted.

• Mandatory step-therapy override grounds: the required drug is contraindicated; the patient already failed it or had an adverse event on it; the patient is stable on the current drug.
• Retrospective review is permitted for a directly related service discovered mid-procedure.
• A denial issued without the specific reason ORC 3923.041 requires is worth naming as a defect on the way into external review.