Ohio external review
Ohio gives you one of the longest filing windows in the country — 180 days — and an unusual two-track system: medical denials go to an accredited Independent Review Organization, while contractual disputes are reviewed directly by Department of Insurance staff. There's no minimum dollar amount, the insurer pays the cost, and the decision binds the insurer.
Deadlines and decision timelines
- Your filing window: 180 days from the final internal denial.
- Standard review decided in: 30 days from the insurer's receipt of your request
- Expedited review decided in: 72 hours — your treating physician certifies the condition could seriously jeopardize your life or health, or for emergency services while still hospitalized; pre-service denials only
- Cost to you: None — the health plan pays external review costs
How to file, step by step
- Finish your plan's internal appeal. External review follows the final adverse benefit determination from your insurer.
- File the request with your insurer — not the state. Ohio routes external review through the health plan: submit your request in writing (electronic counts) to the insurer within 180 days of the final denial (ORC 3922.02).
- The insurer routes it to the right reviewer. Medical-judgment denials are assigned to an accredited Independent Review Organization; contractual, non-medical disputes go to ODI staff for review.
- Decision arrives. The IRO issues a written decision within 30 days of the insurer receiving your request — or within 72 hours on the expedited track, which can be requested orally.
Who can use it
- State-regulated (fully-insured) health benefit plans, for any adverse benefit determination — Ohio law sets no minimum dollar amount.
- Not eligible: employer self-insured (ERISA) plans, which fall outside ODI jurisdiction and use the federal external review process.
What to know
- 180 days from the final internal denial — double the window most states allow.
- Expedited review is not available for services you've already received (retrospective denials).
- The decision is binding on the insurer (ORC 3922.12); no repeat request on the same denial without new medical evidence.
- ODI publishes annual External Review Reports summarizing case outcomes.
Denial data from plans operating in Ohio
| Insurer | Contract / plan | Line | Requests | Denied | Appeals overturned |
|---|---|---|---|---|---|
| Centene | 41047 Ambetter | Marketplace | 52,991 | 28.38% | 56.92% |
| Molina Healthcare | OH-MARKETPLACE | Marketplace | — | 13% | 50% |
| Molina Healthcare | H5280 | Medicare Advantage | — | 9% | 40% |
| Molina Healthcare | H9955 | Medicare Advantage | — | 7% | 53% |
| Elevance Health | H3655 Anthem | Medicare Advantage | — | 6.3% | 79% |
Ohio external review FAQ
Where do I send an Ohio external review request?
To your insurer, not the state. Ohio law (ORC 3922.02) has you file the written request with the health plan within 180 days of the final denial; the plan then assigns it to an Independent Review Organization or forwards contractual disputes to the Department of Insurance.
Does Ohio external review cost anything?
No. The health plan issuer pays the cost of the external review under ORC 3922.18.
How fast is a decision?
Standard reviews are decided within 30 days of the insurer receiving your request. Expedited reviews — when your physician certifies that waiting could seriously jeopardize your life or health — are decided within 72 hours.
Is there a minimum claim amount?
No. Any adverse benefit determination is eligible for internal appeal and external review in Ohio regardless of the healthcare service's cost.
Is the decision final?
The external review decision is binding on the health plan issuer. You keep any other remedies available under state or federal law, but you can't re-file on the same denial without new medical or scientific evidence.
Primary sources
- Ohio Revised Code Chapter 3922 — external review
- ORC 3922.02 — filing window and process
- ORC 3922.09 — expedited review
- ORC 3922.12 — binding effect