OH HMO Affidavit – Poststabilization Timeframe
Last Updated: October 15, 2021 | Letter Type: Affidavits | Jurisdiction: OH HMO
AFFIDAVIT OF COMPLIANCE Poststabilization Care Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of Ohio Rev Code §3923.041(B)(4)(a), which states:... View more
OH HMO Affidavit – Refund Recoupment
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: OH HMO
AFFIDAVIT OF COMPLIANCE Refund Recoupment Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of Ohio Rev Code §3901.388(A,C), which states: (A) A payment made... View more
OH HMO Affidavit – Untimely Payment
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: OH HMO
AFFIDAVIT OF COMPLIANCE Prompt Payment to Providers Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of Ohio Rev... View more
OH HMO Appeal – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: OH HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Ohio Department of Insurance for ‘s failure to reimburse emergency services as required by state law. Our investigation has concluded the following: As the services rendered were emergent, was not required to obtain authorization per Ohio Rev... View more
OH HMO Appeal – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: OH HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Ohio Department of Insurance for ‘s failure to meet the timeframe and notice requirements for non-urgent authorization requests as required by state law. Our investigation has concluded the following: THIS REQUEST IS NOW DAYS IN VIOLATION OF... View more
OH HMO Appeal – Poststabilization Timeframe
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: OH HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Ohio Department of Insurance for ’s failure to reimburse emergency and/or statutorily granted post-stabilization services and care as required by state law. Our investigation has concluded the following: TO DATE, HAS FAILED TO REIMBURSE EMERGENCY AND... View more
OH HMO Appeal – Refund Recoupment
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: OH HMO
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Ohio Department of Insurance for ’s failure to properly reimburse medically necessary services as required by state law. Our investigation has concluded the following: Please be advised that must substantiate how it reached its overpayment determination... View more
OH HMO Appeal – Untimely Payment
Last Updated: October 15, 2021 | Letter Type: Appeals | Jurisdiction: OH HMO
URGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Ohio Department of Insurance for ‘s failure to remit timely payment on this claim as required by state law. Our investigation has concluded the following: Per Ohio Rev Code §3901.381(B)(1), was required to reimburse within the... View more
OR HMO Fax Cover Sheet – Competent Reviewer Request
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: OR HMO
COMPETENT REVIEWER REQUEST : Oregon law requires that all final recommendations regarding the necessity or appropriateness of services be conducted by a licensed physician in consultation with medical or mental health specialists as appropriate, per ORS 743B.422(2). At this time, please provide all reviewing physician’s name/job title, field of... View more
OR HMO Fax Cover Sheet – Notification of Disagreement of Care
Last Updated: December 30, 2024 | Letter Type: Fax Cover Sheets | Jurisdiction: OR HMO
NOTIFICATION OF DISAGREEMENT OF CARE On , you notified our facility that further post-stabilization care was denied. This notice serves as a formal NOTICE OF DISAGREEMENT OF CARE. : Federal regulations mandate that you are financially responsible for post-stabilization care services until (1) a plan physician with privileges... View more