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Ohio Department of Insurance ODI Services

Independent External Review Organization Selection Process
Please verify the information entered on the previous screen. If correct, click the Continue button. If the information is NOT correct, click the Change Data button.
Type of Health Plan Issuer:
Federal ID Number:
Health Plan Issuer Name:
Health Plan Issuer Contact Name:
Health Plan Issuer Contact Phone Number:
Health Plan Issuer Contact Email:
Patient Name (Last, First, MI):
Reason for Adverse Determination:
Date Request Received:
External Review Requested By:
Related Case Number:
TPA Name:
TPA Phone Number:
TPA Email:
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