Ohio Prior Authorization Law

Overview

Ohio HB 122 (2024) sets strict prior authorization timelines: 5 business days for standard requests and 48 hours for urgent requests. All denials require clinical rationale grounded in medical policy and the patient's presentation. This protects patient access to necessary care.

Key Requirements

1. Insurers must acknowledge PA requests within 24 hours and provide decision timeline.
2. Standard PA decisions within 5 business days; urgent decisions within 48 hours.
3. All PA denials must include specific clinical rationale tied to policy and patient presentation.
4. Providers may request expedited review if standard timeline is medically inappropriate.
5. Appeal procedures and external review access must accompany each denial.

Penalties and Enforcement

The Ohio Department of Insurance enforces HB 122 PA requirements. Insurers who miss deadlines or deny without clinical rationale face fines. Providers may bill at usual and customary rates if insurer misses deadline. Repeat violations trigger license sanctions and increased penalties.

Appeals and Exceptions

Urgent PA requests receive expedited 48-hour response. Denials may be appealed within 10 business days. Independent external review is available if internal appeals fail. Certain denial codes may trigger automatic expedited review.

Interaction with Federal Law

Ohio PA timelines align with federal standards. The 48-hour urgent timeline matches federal requirements. Ohio's clinical rationale requirement exceeds federal standards. Providers benefit from Ohio's stricter documentation requirements. NSA rules complement PA timelines.

Common Questions