Written by a parent, not a doctor. Nothing here is medical advice.

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Ohio program

Deadlines for treatment approval and step-therapy exceptions

Ohio sets response deadlines when covered plans receive qualifying electronic requests for treatment approval.

What it is

Ohio sets response deadlines when covered plans receive qualifying electronic requests for treatment approval.

A pending treatment request can delay care. Ohio's response clocks cover qualifying electronic prior-approval requests and requests to skip step therapy. The clinic can identify the submission date and whether the urgent rules apply.

Eligibility rules
  • ORC 3923.041 covers sickness-and-accident policies and public-employee benefit plans. The electronic-request conditions matter.
  • The cited electronic prior-authorization requirements apply under the law to covered policies or plans issued or renewed from January 1, 2018.
  • Step-therapy exemptions follow ORC 3901.832 and the incorporated plan definitions.
  • The Ohio clocks depend on the plan and request. Covered electronic prior-authorization requests under the insurance law have 48-hour urgent and 10-calendar-day routine limits. Step-therapy exception requests and appeals have separate 48-hour/10-day rules, including deemed approval when that law's clock is missed. Ohio public-employee plans may be covered; a private-employer ERISA self-funded plan generally is not. The social worker can help confirm the policy's issuing state, legal type and applicable procedure.
What you get
  • A 48-hour urgent response deadline and a 10-calendar-day routine deadline.
  • The same time limits for a request to skip step therapy.
What this covers
  • The law provides a deadline for a decision on covered requests, including a request to bypass a required trial of another treatment.
If you decide to apply
  1. Ask the clinic when it sent the electronic request and whether it meets the urgent-review conditions.
  2. If the response is late, ask the social worker to help you raise the missed deadline with the plan or Department of Insurance.

Ohio Department of Insurance: 800-686-1526 · Official page ↗

After you apply
  • The clinic and plan can identify when the clock started and what decision or missing-information notice was issued.
Good to know

A normal response can be a denial, but a missed deadline under the step-therapy exception law can have a deemed-approval consequence. The clinic should identify which request and clock are involved.

Other details
  • HB 220 remained pending; its proposed gold-card exemptions were not enacted. The clinic can ask about a plan's own exemption policy while following the existing approval and appeal rules.
  • A separate HMO provision supplies a five-day continuity rule in specified circumstances.
  • A separate HMO network rule preserves payment for covered services through five days after the required provider-termination notice is mailed; it is not a general extension of a denied approval. Federal law may offer a qualifying continuing-care patient up to 90 days at the previous in-network terms after notice of a covered network change. For active cancer treatment, the social worker can help the clinic request a written transition plan and confirm which protection applies. Federal continuity can end sooner when continuing-care status ends and excludes certain quality or fraud terminations.
Official sources
Ask your social worker

“Which deadline applies to our clinic's request, and would urgent review or a step-therapy exception help? Could you help us weigh the options and follow up if needed?”

Why I’m asking: I want to understand how long the plan can leave needed treatment pending.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Ask the clinic for the date the request went in. If the deadline passes, quote it to the plan.

Your social worker

The social worker chases the approval and files the Department of Insurance complaint if needed.

The care team

Files the request electronically and marks urgent requests as urgent.

Who decides
The plan decides within the legal deadline. The Ohio Department of Insurance enforces it.
Ask the care team
“Was the prior approval sent electronically, and when? Ohio gives the plan 48 hours if urgent and 10 days otherwise. Can we mark it urgent?”

How to apply

First step: Ask the clinic when the request went in, whether it was electronic, and whether it was marked urgent. If the deadline has passed, call the plan, then the Department of Insurance at 800-686-1526.

  1. Ask the clinic which prior authorizations are pending and whether they went in electronically.

Official application / program page ↗

Where it starts: Ask the clinic to submit electronically and to cite the 48-hour / 10-day clock; complain to the Department of Insurance at 800-686-1526 if it lapses

What to gather

  • Submission date and reference number
  • Plan ID

How long: 48 hours if urgent; 10 calendar days otherwise.

What a yes looks like

An approval within the deadline.

What a no looks like, and the next move

A written denial starts the plan appeal, and then Ohio external review.

Watch out

  • The deadline runs on electronic requests that meet the law's conditions. Ask the clinic to file electronically.
  • Ohio has no 'gold card' rule yet (a rule that lets trusted doctors skip prior approval).
  • A separate HMO network rule preserves payment for covered services through five days after the required provider-termination notice is mailed; it is not a general extension of a denied approval. Federal law may offer a qualifying continuing-care patient up to 90 days at the previous in-network terms after notice of a covered network change. For active cancer treatment, the social worker can help the clinic request a written transition plan and confirm which protection applies. Federal continuity can end sooner when continuing-care status ends and excludes certain quality or fraud terminations.
  • The state-employee, STRS or other public plan administrator can confirm the current handbook and external-review procedure. The plan's funding type alone does not settle the route.

If they say no, quote this: Ohio Revised Code 3923.041 (prior-authorization deadlines: 48 hours urgent, 10 calendar days otherwise) and 3901.832 (step-therapy exemption requests, same deadlines).

Dates that change this

2026-09-08: A 'gold card' bill to let trusted doctors skip prior approval (HB 220) passed the Ohio House but was not law as of September 8, 2026. (not yet confirmed against the final rule)

The numbers and the rules

The arcane layer, kept on purpose. Checked September 10, 2026.

What it is worth

48 hours (urgent) or 10 calendar days (routine) to answer an electronic prior-approval request. The same deadlines for a request to skip step therapy.

  • $48 (covered policies issued or renewed from January 1, 2018) — Urgent electronic prior-authorization decision
  • $10 — Non-urgent electronic prior-authorization decision
  • $48 — Urgent step-therapy exemption decision
  • $10 — Other step-therapy exemption decision

Legal protection: Prior-authorization response clocks for electronic requests (ORC 3923.041) · Step-therapy exemption request clocks (ORC 3901.832) · HMO pays covered primary-care and hospital services for 5 days after a provider-termination notice is mailed (ORC 1751.13; a short provision, not oncology continuity)

What it costs the family: None.

The eligibility facts, as published

Plans
policies of sickness and accident insurance and public employee benefit plans ("covered person" in 3923.041); step therapy imports the 3922.01 plan definitions
Self funded
applicability NOT FOUND (ERISA preemption expected)
Gold card
NOT enacted; HB 220 passed the House only
Continuity
A separate HMO network rule preserves payment for covered services through five days after the required provider-termination notice is mailed; it is not a general extension of a denied approval. Federal law may offer a qualifying continuing-care patient up to 90 days at the previous in-network terms after notice of a covered network change. For active cancer treatment, the social worker can help the clinic request a written transition plan and confirm which protection applies. Federal continuity can end sooner when continuing-care status ends and excludes certain quality or fraud terminations.

Expect friction on: Electronic-submission conditions

The trap: The deadlines apply to electronic requests that meet the law's conditions, so ask the clinic to send it electronically. Ohio has no 'gold card' rule that lets trusted doctors skip prior approval (a House bill passed one chamber only).

Where I read this

← Back to your options