Minnesota Legislature
Office of the Revisor of Statutes
Minnesota Session Laws - 1999, Regular Session
Key: (1) language to be deleted (2) new language
CHAPTER 239-S.F.No. 1219
An act relating to health; establishing a uniform
complaint resolution process for health plan
companies; establishing an external review process;
amending Minnesota Statutes 1998, sections 62D.11,
subdivision 1; 62M.01; 62M.02, subdivisions 3, 4, 5,
6, 7, 9, 10, 11, 12, 17, 20, 21, and by adding a
subdivision; 62M.03, subdivisions 1 and 3; 62M.04,
subdivisions 1, 2, 3, and 4; 62M.05; 62M.06; 62M.07;
62M.09, subdivision 3; 62M.10, subdivisions 2, 5, and
7; 62M.12; 62M.15; 62Q.106; 62Q.19, subdivision 5a;
62T.04; 72A.201, subdivision 4a; and 256B.692,
subdivision 2; proposing coding for new law in
Minnesota Statutes, chapters 62D; and 62Q; repealing
Minnesota Statutes 1998, sections 62D.11, subdivisions
1b and 2; 62Q.105; 62Q.11; and 62Q.30; Minnesota
Rules, parts 4685.0100, subparts 4 and 4a; 4685.1010,
subpart 3; and 4685.1700.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
Section 1. Minnesota Statutes 1998, section 62D.11,
subdivision 1, is amended to read:
Subdivision 1. [ENROLLEE COMPLAINT SYSTEM.] Every health
maintenance organization shall establish and maintain a
complaint system, as required under section 62Q.105 sections
62Q.68 to 62Q.72 to provide reasonable procedures for the
resolution of written complaints initiated by or on behalf of
enrollees concerning the provision of health care
services. "Provision of health services" includes, but is not
limited to, questions of the scope of coverage, quality of care,
and administrative operations. The health maintenance
organization must inform enrollees that they may choose to use
arbitration to appeal a health maintenance organization's
internal appeal decision. The health maintenance organization
must also inform enrollees that they have the right to use
arbitration to appeal a health maintenance organization's
internal appeal decision not to certify an admission, procedure,
service, or extension of stay under section 62M.06. If an
enrollee chooses to use arbitration, the health maintenance
organization must participate.
Sec. 2. [62D.124] [GEOGRAPHIC ACCESSIBILITY.]
Subdivision 1. [PRIMARY CARE; MENTAL HEALTH SERVICES;
GENERAL HOSPITAL SERVICES.] Within the health maintenance
organization's service area, the maximum travel distance or time
shall be the lesser of 30 miles or 30 minutes to the nearest
provider of each of the following services: primary care
services, mental health services, and general hospital
services. The health maintenance organization must designate
which method is used.
Subd. 2. [OTHER HEALTH SERVICES.] Within a health
maintenance organization's service area, the maximum travel
distance or time shall be the lesser of 60 miles or 60 minutes
to the nearest provider of specialty physician services,
ancillary services, specialized hospital services, and all other
health services not listed in subdivision 1. The health
maintenance organization must designate which method is used.
Subd. 3. [EXCEPTION.] The commissioner shall grant an
exception to the requirements of this section according to
Minnesota Rules, part 4685.1010, subpart 4, if the health
maintenance organization can demonstrate with specific data that
the requirement of subdivision 1 or 2 is not feasible in a
particular service area or part of a service area.
Subd. 4. [APPLICATION.] (a) Subdivisions 1 and 2 do not
apply if an enrollee is referred to a referral center for health
care services.
(b) Subdivision 1 does not apply:
(1) if an enrollee has chosen a health plan with full
knowledge that the health plan has no participating providers
within 30 miles or 30 minutes of the enrollee's place of
residence; or
(2) to service areas approved before May 24, 1993.
Sec. 3. Minnesota Statutes 1998, section 62M.01, is
amended to read:
62M.01 [CITATION, JURISDICTION, AND SCOPE.]
Subdivision 1. [POPULAR NAME.] Sections 62M.01 to 62M.16
may be cited as the "Minnesota Utilization Review Act of 1992."
Subd. 2. [JURISDICTION.] Sections 62M.01 to 62M.16 apply
to any insurance company licensed under chapter 60A to offer,
sell, or issue a policy of accident and sickness insurance as
defined in section 62A.01; a health service plan licensed under
chapter 62C; a health maintenance organization licensed under
chapter 62D; a community integrated service network licensed
under chapter 62N; an accountable provider network operating
under chapter 62T; a fraternal benefit society operating under
chapter 64B; a joint self-insurance employee health plan
operating under chapter 62H; a multiple employer welfare
arrangement, as defined in section 3 of the Employee Retirement
Income Security Act of 1974 (ERISA), United States Code, title
29, section 1103, as amended; a third party administrator
licensed under section 60A.23, subdivision 8, that provides
utilization review services for the administration of benefits
under a health benefit plan as defined in section 62M.02; or any
entity performing utilization review on behalf of a business
entity in this state pursuant to a health benefit plan covering
a Minnesota resident.
Subd. 3. [SCOPE.] Sections 62M.02, 62M.07, and 62M.09,
subdivision 4, apply to prior authorization of services.
Nothing in sections 62M.01 to 62M.16 applies to review of claims
after submission to determine eligibility for benefits under a
health benefit plan. The appeal procedure described in section
62M.06 applies to any complaint as defined under section 62Q.68,
subdivision 2, that requires a medical determination in its
resolution.
Sec. 4. Minnesota Statutes 1998, section 62M.02,
subdivision 3, is amended to read:
Subd. 3. [ATTENDING DENTIST.] "Attending dentist" means
the dentist with primary responsibility for the dental care
provided to a patient an enrollee.
Sec. 5. Minnesota Statutes 1998, section 62M.02,
subdivision 4, is amended to read:
Subd. 4. [ATTENDING PHYSICIAN HEALTH CARE PROFESSIONAL.]
"Attending physician health care professional" means
the physician health care professional providing care within the
scope of their practice and with primary responsibility for the
care provided to a patient in a hospital or other health care
facility an enrollee. Attending health care professional shall
include only physicians; chiropractors; dentists; mental health
professionals as defined in section 245.462, subdivision 18, or
section 245.4871, subdivision 27; podiatrists; and advanced
practice nurses.
Sec. 6. Minnesota Statutes 1998, section 62M.02,
subdivision 5, is amended to read:
Subd. 5. [CERTIFICATION.] "Certification" means a
determination by a utilization review organization that an
admission, extension of stay, or other health care service has
been reviewed and that it, based on the information provided,
meets the utilization review requirements of the applicable
health plan and the health carrier plan company will then pay
for the covered benefit, provided the preexisting limitation
provisions, the general exclusion provisions, and any
deductible, copayment, coinsurance, or other policy requirements
have been met.
Sec. 7. Minnesota Statutes 1998, section 62M.02,
subdivision 6, is amended to read:
Subd. 6. [CLAIMS ADMINISTRATOR.] "Claims administrator"
means an entity that reviews and determines whether to pay
claims to enrollees, physicians, hospitals, or others or
providers based on the contract provisions of the health plan
contract. Claims administrators may include insurance companies
licensed under chapter 60A to offer, sell, or issue a policy of
accident and sickness insurance as defined in section 62A.01; a
health service plan licensed under chapter 62C; a health
maintenance organization licensed under chapter 62D; a community
integrated service network licensed under chapter 62N; an
accountable provider network operating under chapter 62T; a
fraternal benefit society operating under chapter 64B; a
multiple employer welfare arrangement, as defined in section 3
of the Employee Retirement Income Security Act of 1974 (ERISA),
United States Code, title 29, section 1103, as amended.
Sec. 8. Minnesota Statutes 1998, section 62M.02,
subdivision 7, is amended to read:
Subd. 7. [CLAIMANT.] "Claimant" means the enrollee or
covered person who files a claim for benefits or a provider of
services who, pursuant to a contract with a claims
administrator, files a claim on behalf of an enrollee or covered
person.
Sec. 9. Minnesota Statutes 1998, section 62M.02,
subdivision 9, is amended to read:
Subd. 9. [CONCURRENT REVIEW.] "Concurrent review" means
utilization review conducted during a patient's an enrollee's
hospital stay or course of treatment and has the same meaning as
continued stay review.
Sec. 10. Minnesota Statutes 1998, section 62M.02,
subdivision 10, is amended to read:
Subd. 10. [DISCHARGE PLANNING.] "Discharge planning" means
the process that assesses a patient's an enrollee's need for
treatment after hospitalization in order to help arrange for the
necessary services and resources to effect an appropriate and
timely discharge.
Sec. 11. Minnesota Statutes 1998, section 62M.02,
subdivision 11, is amended to read:
Subd. 11. [ENROLLEE.] "Enrollee" means an individual who
has elected to contract for, or participate in, a health benefit
plan for enrollee coverage or for dependent coverage covered by
a health benefit plan and includes an insured policyholder,
subscriber, contract holder, member, covered person, or
certificate holder.
Sec. 12. Minnesota Statutes 1998, section 62M.02,
subdivision 12, is amended to read:
Subd. 12. [HEALTH BENEFIT PLAN.] "Health benefit plan"
means a policy, contract, or certificate issued by a health
carrier to an employer or individual plan company for the
coverage of medical, dental, or hospital benefits. A health
benefit plan does not include coverage that is:
(1) limited to disability or income protection coverage;
(2) automobile medical payment coverage;
(3) supplemental to liability insurance;
(4) designed solely to provide payments on a per diem,
fixed indemnity, or nonexpense incurred basis;
(5) credit accident and health insurance issued under
chapter 62B;
(6) blanket accident and sickness insurance as defined in
section 62A.11;
(7) accident only coverage issued by a licensed and tested
insurance agent; or
(8) workers' compensation.
Sec. 13. Minnesota Statutes 1998, section 62M.02, is
amended by adding a subdivision to read:
Subd. 12a. [HEALTH PLAN COMPANY.] "Health plan company"
means a health plan company as defined in section 62Q.01,
subdivision 4, and includes an accountable provider network
operating under chapter 62T.
Sec. 14. Minnesota Statutes 1998, section 62M.02,
subdivision 17, is amended to read:
Subd. 17. [PROVIDER.] "Provider" means a licensed health
care facility, physician, or other health care professional that
delivers health care services to an enrollee or covered person.
Sec. 15. Minnesota Statutes 1998, section 62M.02,
subdivision 20, is amended to read:
Subd. 20. [UTILIZATION REVIEW.] "Utilization review" means
the evaluation of the necessity, appropriateness, and efficacy
of the use of health care services, procedures, and facilities,
by a person or entity other than the attending physician health
care professional, for the purpose of determining the medical
necessity of the service or admission. Utilization review also
includes review conducted after the admission of the enrollee.
It includes situations where the enrollee is unconscious or
otherwise unable to provide advance notification. Utilization
review does not include the imposition of a requirement that
services be received by or upon referral from a participating
provider a referral or participation in a referral process by a
participating provider unless the provider is acting as a
utilization review organization.
Sec. 16. Minnesota Statutes 1998, section 62M.02,
subdivision 21, is amended to read:
Subd. 21. [UTILIZATION REVIEW ORGANIZATION.] "Utilization
review organization" means an entity including but not limited
to an insurance company licensed under chapter 60A to offer,
sell, or issue a policy of accident and sickness insurance as
defined in section 62A.01; a health service plan licensed under
chapter 62C; a health maintenance organization licensed under
chapter 62D; a community integrated service network licensed
under chapter 62N; an accountable provider network operating
under chapter 62T; a fraternal benefit society operating under
chapter 64B; a joint self-insurance employee health plan
operating under chapter 62H; a multiple employer welfare
arrangement, as defined in section 3 of the Employee Retirement
Income Security Act of 1974 (ERISA), United States Code, title
29, section 1103, as amended; a third party administrator
licensed under section 60A.23, subdivision 8, which conducts
utilization review and determines certification of an admission,
extension of stay, or other health care services for a Minnesota
resident; or any entity performing utilization review that is
affiliated with, under contract with, or conducting utilization
review on behalf of, a business entity in this state.
Sec. 17. Minnesota Statutes 1998, section 62M.03,
subdivision 1, is amended to read:
Subdivision 1. [LICENSED UTILIZATION REVIEW ORGANIZATION.]
Beginning January 1, 1993, any organization that meets the
definition of utilization review organization in section 62M.02,
subdivision 21, must be licensed under chapter 60A, 62C, 62D,
62N, 62T, or 64B, or registered under this chapter and must
comply with sections 62M.01 to 62M.16 and section 72A.201,
subdivisions 8 and 8a. Each licensed community integrated
service network or health maintenance organization that has an
employed staff model of providing health care services shall
comply with sections 62M.01 to 62M.16 and section 72A.201,
subdivisions 8 and 8a, for any services provided by providers
under contract.
Sec. 18. Minnesota Statutes 1998, section 62M.03,
subdivision 3, is amended to read:
Subd. 3. [PENALTIES AND ENFORCEMENTS.] If a utilization
review organization fails to comply with sections 62M.01 to
62M.16, the organization may not provide utilization review
services for any Minnesota resident. The commissioner of
commerce may issue a cease and desist order under section
45.027, subdivision 5, to enforce this provision. The cease and
desist order is subject to appeal under chapter 14. A
nonlicensed utilization review organization that fails to comply
with the provisions of sections 62M.01 to 62M.16 is subject to
all applicable penalty and enforcement provisions of section
72A.201. Each utilization review organization licensed under
chapter 60A, 62C, 62D, 62N, 62T, or 64B shall comply with
sections 62M.01 to 62M.16 as a condition of licensure.
Sec. 19. Minnesota Statutes 1998, section 62M.04,
subdivision 1, is amended to read:
Subdivision 1. [RESPONSIBILITY FOR OBTAINING
CERTIFICATION.] A health benefit plan that includes utilization
review requirements must specify the process for notifying the
utilization review organization in a timely manner and obtaining
certification for health care services. Each health plan
company must provide a clear and concise description of this
process to an enrollee as part of the policy, subscriber
contract, or certificate of coverage. In addition to the
enrollee, the utilization review organization must allow any
licensed hospital, physician or the physician's provider or
provider's designee, or responsible patient representative,
including a family member, to fulfill the obligations under the
health plan.
A claims administrator that contracts directly with
providers for the provision of health care services to enrollees
may, through contract, require the provider to notify the review
organization in a timely manner and obtain certification for
health care services.
Sec. 20. Minnesota Statutes 1998, section 62M.04,
subdivision 2, is amended to read:
Subd. 2. [INFORMATION UPON WHICH UTILIZATION REVIEW IS
CONDUCTED.] If the utilization review organization is conducting
routine prospective and concurrent utilization review,
utilization review organizations must collect only the
information necessary to certify the admission, procedure of
treatment, and length of stay.
(a) Utilization review organizations may request, but may
not require, hospitals, physicians, or other providers to supply
numerically encoded diagnoses or procedures as part of the
certification process.
(b) Utilization review organizations must not routinely
request copies of medical records for all patients reviewed. In
performing prospective and concurrent review, copies of the
pertinent portion of the medical record should be required only
when a difficulty develops in certifying the medical necessity
or appropriateness of the admission or extension of stay.
(c) Utilization review organizations may request copies of
medical records retrospectively for a number of purposes,
including auditing the services provided, quality assurance
review, ensuring compliance with the terms of either the health
benefit plan or the provider contract, and compliance with
utilization review activities. Except for reviewing medical
records associated with an appeal or with an investigation or
audit of data discrepancies, health care providers must be
reimbursed for the reasonable costs of duplicating records
requested by the utilization review organization for
retrospective review unless otherwise provided under the terms
of the provider contract.
Sec. 21. Minnesota Statutes 1998, section 62M.04,
subdivision 3, is amended to read:
Subd. 3. [DATA ELEMENTS.] Except as otherwise provided in
sections 62M.01 to 62M.16, for purposes of certification a
utilization review organization must limit its data requirements
to the following elements:
(a) Patient information that includes the following:
(1) name;
(2) address;
(3) date of birth;
(4) sex;
(5) social security number or patient identification
number;
(6) name of health carrier plan company or health plan; and
(7) plan identification number.
(b) Enrollee information that includes the following:
(1) name;
(2) address;
(3) social security number or employee identification
number;
(4) relation to patient;
(5) employer;
(6) health benefit plan;
(7) group number or plan identification number; and
(8) availability of other coverage.
(c) Attending physician or provider health care
professional information that includes the following:
(1) name;
(2) address;
(3) telephone numbers;
(4) degree and license;
(5) specialty or board certification status; and
(6) tax identification number or other identification
number.
(d) Diagnosis and treatment information that includes the
following:
(1) primary diagnosis with associated ICD or DSM coding, if
available;
(2) secondary diagnosis with associated ICD or DSM coding,
if available;
(3) tertiary diagnoses with associated ICD or DSM coding,
if available;
(4) proposed procedures or treatments with ICD or
associated CPT codes, if available;
(5) surgical assistant requirement;
(6) anesthesia requirement;
(7) proposed admission or service dates;
(8) proposed procedure date; and
(9) proposed length of stay.
(e) Clinical information that includes the following:
(1) support and documentation of appropriateness and level
of service proposed; and
(2) identification of contact person for detailed clinical
information.
(f) Facility information that includes the following:
(1) type;
(2) licensure and certification status and DRG exempt
status;
(3) name;
(4) address;
(5) telephone number; and
(6) tax identification number or other identification
number.
(g) Concurrent or continued stay review information that
includes the following:
(1) additional days, services, or procedures proposed;
(2) reasons for extension, including clinical information
sufficient for support of appropriateness and level of service
proposed; and
(3) diagnosis status.
(h) For admissions to facilities other than acute medical
or surgical hospitals, additional information that includes the
following:
(1) history of present illness;
(2) patient treatment plan and goals;
(3) prognosis;
(4) staff qualifications; and
(5) 24-hour availability of staff.
Additional information may be required for other specific
review functions such as discharge planning or catastrophic case
management. Second opinion information may also be required,
when applicable, to support benefit plan requirements.
Sec. 22. Minnesota Statutes 1998, section 62M.04,
subdivision 4, is amended to read:
Subd. 4. [ADDITIONAL INFORMATION.] A utilization review
organization may request information in addition to that
described in subdivision 3 when there is significant lack of
agreement between the utilization review organization and the
health care provider regarding the appropriateness of
certification during the review or appeal process. For purposes
of this subdivision, "significant lack of agreement" means that
the utilization review organization has:
(1) tentatively determined through its professional staff
that a service cannot be certified;
(2) referred the case to a physician for review; and
(3) talked to or attempted to talk to the attending
physician health care professional for further information.
Nothing in sections 62M.01 to 62M.16 prohibits a
utilization review organization from requiring submission of
data necessary to comply with the quality assurance and
utilization review requirements of chapter 62D or other
appropriate data or outcome analyses.
Sec. 23. Minnesota Statutes 1998, section 62M.05, is
amended to read:
62M.05 [PROCEDURES FOR REVIEW DETERMINATION.]
Subdivision 1. [WRITTEN PROCEDURES.] A utilization review
organization must have written procedures to ensure that reviews
are conducted in accordance with the requirements of this
chapter and section 72A.201, subdivision 4a.
Subd. 2. [CONCURRENT REVIEW.] A utilization review
organization may review ongoing inpatient stays based on the
severity or complexity of the patient's enrollee's condition or
on necessary treatment or discharge planning activities. Such
review must not be consistently conducted on a daily basis.
Subd. 3. [NOTIFICATION OF DETERMINATIONS.] A utilization
review organization must have written procedures for providing
notification of its determinations on all certifications in
accordance with the following: this section.
Subd. 3a. [STANDARD REVIEW DETERMINATION.] (a)
Notwithstanding subdivision 3b, an initial determination on all
requests for utilization review must be communicated to the
provider and enrollee in accordance with this subdivision within
ten business days of the request, provided that all information
reasonably necessary to make a determination on the request has
been made available to the utilization review organization.
(b) When an initial determination is made to certify,
notification must be provided promptly by telephone to the
provider. The utilization review organization shall send
written notification to the hospital, attending physician, or
applicable service provider within ten business days of the
determination in accordance with section 72A.201, subdivision
4a, provider or shall maintain an audit trail of the
determination and telephone notification. For purposes of this
subdivision, "audit trail" includes documentation of the
telephone notification, including the date; the name of the
person spoken to; the enrollee or patient; the service,
procedure, or admission certified; and the date of the service,
procedure, or admission. If the utilization review organization
indicates certification by use of a number, the number must be
called the "certification number."
(b) (c) When a an initial determination is made not to
certify a hospital or surgical facility admission or extension
of a hospital stay, or other service requiring review
determination, notification must be provided by telephone within
one working day after making the decision determination to the
attending physician health care professional and hospital must
be notified by telephone and a written notification must be sent
to the hospital, attending physician health care professional,
and enrollee or patient. The written notification must include
the principal reason or reasons for the determination and the
process for initiating an appeal of the determination. Upon
request, the utilization review organization shall provide
the attending physician or provider or enrollee with the
criteria used to determine the necessity, appropriateness, and
efficacy of the health care service and identify the database,
professional treatment parameter, or other basis for the
criteria. Reasons for a determination not to certify may
include, among other things, the lack of adequate information to
certify after a reasonable attempt has been made to contact
the attending physician provider or enrollee.
(d) When an initial determination is made not to certify,
the written notification must inform the enrollee and the
attending health care professional of the right to submit an
appeal to the internal appeal process described in section
62M.06 and the procedure for initiating the internal appeal.
Subd. 3b. [EXPEDITED REVIEW DETERMINATION.] (a) An
expedited initial determination must be utilized if the
attending health care professional believes that an expedited
determination is warranted.
(b) Notification of an expedited initial determination to
either certify or not to certify must be provided to the
hospital, the attending health care professional, and the
enrollee as expeditiously as the enrollee's medical condition
requires, but no later than 72 hours from the initial request.
When an expedited initial determination is made not to certify,
the utilization review organization must also notify the
enrollee and the attending health care professional of the right
to submit an appeal to the expedited internal appeal as
described in section 62M.06 and the procedure for initiating an
internal expedited appeal.
Subd. 4. [FAILURE TO PROVIDE NECESSARY INFORMATION.] A
utilization review organization must have written procedures to
address the failure of a health care provider, patient, or
representative of either or enrollee to provide the necessary
information for review. If the patient enrollee or provider
will not release the necessary information to the utilization
review organization, the utilization review organization may
deny certification in accordance with its own policy or the
policy described in the health benefit plan.
Subd. 5. [NOTIFICATION TO CLAIMS ADMINISTRATOR.] If the
utilization review organization and the claims administrator are
separate entities, the utilization review organization must
forward, electronically or in writing, a notification of
certification or determination not to certify to the appropriate
claims administrator for the health benefit plan.
Sec. 24. Minnesota Statutes 1998, section 62M.06, is
amended to read:
62M.06 [APPEALS OF DETERMINATIONS NOT TO CERTIFY.]
Subdivision 1. [PROCEDURES FOR APPEAL.] A utilization
review organization must have written procedures for appeals of
determinations not to certify an admission, procedure, service,
or extension of stay. The right to appeal must be available to
the enrollee or designee and to the attending physician health
care professional. The right of appeal must be communicated to
the enrollee or designee or to the attending physician, whomever
initiated the original certification request, at the time that
the original determination is communicated.
Subd. 2. [EXPEDITED APPEAL.] (a) When an initial
determination not to certify a health care service is made prior
to or during an ongoing service requiring review, and the
attending physician health care professional believes that the
determination warrants immediate an expedited appeal, the
utilization review organization must ensure that the enrollee
and the attending physician, enrollee, or designee has health
care professional have an opportunity to appeal the
determination over the telephone on an expedited basis. In such
an appeal, the utilization review organization must ensure
reasonable access to its consulting physician or health care
provider. Expedited appeals that are not resolved may be
resubmitted through the standard appeal process.
(b) The utilization review organization shall notify the
enrollee and attending health care professional by telephone of
its determination on the expedited appeal as expeditiously as
the enrollee's medical condition requires, but no later than 72
hours after receiving the expedited appeal.
(c) If the determination not to certify is not reversed
through the expedited appeal, the utilization review
organization must include in its notification the right to
submit the appeal to the external appeal process described in
section 62Q.73 and the procedure for initiating the process.
This information must be provided in writing to the enrollee and
the attending health care professional as soon as practical.
Subd. 3. [STANDARD APPEAL.] The utilization review
organization must establish procedures for appeals to be made
either in writing or by telephone.
(a) Each A utilization review organization shall notify in
writing the enrollee or patient, attending physician health care
professional, and claims administrator of its determination on
the appeal as soon as practical, but in no case later than 45
days after receiving the required documentation on the
appeal within 30 days upon receipt of the notice of appeal. If
the utilization review organization cannot make a determination
within 30 days due to circumstances outside the control of the
utilization review organization, the utilization review
organization may take up to 14 additional days to notify the
enrollee, attending health care professional, and claims
administrator of its determination. If the utilization review
organization takes any additional days beyond the initial 30-day
period to make its determination, it must inform the enrollee,
attending health care professional, and claims administrator, in
advance, of the extension and the reasons for the extension.
(b) The documentation required by the utilization review
organization may include copies of part or all of the medical
record and a written statement from the attending health care
provider professional.
(c) Prior to upholding the original decision initial
determination not to certify for clinical reasons, the
utilization review organization shall conduct a review of the
documentation by a physician who did not make the original
initial determination not to certify.
(d) The process established by a utilization review
organization may include defining a period within which an
appeal must be filed to be considered. The time period must be
communicated to the patient, enrollee, or and attending
physician health care professional when the initial
determination is made.
(e) An attending physician health care professional or
enrollee who has been unsuccessful in an attempt to reverse a
determination not to certify shall, consistent with section
72A.285, be provided the following:
(1) a complete summary of the review findings;
(2) qualifications of the reviewers, including any license,
certification, or specialty designation; and
(3) the relationship between the enrollee's diagnosis and
the review criteria used as the basis for the decision,
including the specific rationale for the reviewer's decision.
(f) In cases of appeal to reverse a determination not to
certify for clinical reasons, the utilization review
organization must, upon request of the attending physician
health care professional, ensure that a physician of the
utilization review organization's choice in the same or a
similar general specialty as typically manages the medical
condition, procedure, or treatment under discussion is
reasonably available to review the case.
(g) If the initial determination is not reversed on appeal,
the utilization review organization must include in its
notification the right to submit the appeal to the external
review process described in section 62Q.73 and the procedure for
initiating the external process.
Subd. 4. [NOTIFICATION TO CLAIMS ADMINISTRATOR.] If the
utilization review organization and the claims administrator are
separate entities, the utilization review organization
must forward notify, either electronically or in writing, a
notification of certification or determination not to certify to
the appropriate claims administrator for the health benefit plan
of any determination not to certify that is reversed on appeal.
Sec. 25. Minnesota Statutes 1998, section 62M.07, is
amended to read:
62M.07 [PRIOR AUTHORIZATION OF SERVICES.]
(a) Utilization review organizations conducting prior
authorization of services must have written standards that meet
at a minimum the following requirements:
(1) written procedures and criteria used to determine
whether care is appropriate, reasonable, or medically necessary;
(2) a system for providing prompt notification of its
determinations to enrollees and providers and for notifying the
provider, enrollee, or enrollee's designee of appeal procedures
under clause (4);
(3) compliance with section 72A.201 62M.05, subdivision 4a
subdivisions 3a and 3b, regarding time frames for approving and
disapproving prior authorization requests;
(4) written procedures for appeals of denials of prior
authorization which specify the responsibilities of the enrollee
and provider, and which meet the requirements of section
sections 62M.06 and 72A.285, regarding release of summary review
findings; and
(5) procedures to ensure confidentiality of
patient-specific information, consistent with applicable law.
(b) No utilization review organization, health plan
company, or claims administrator may conduct or require prior
authorization of emergency confinement or emergency treatment.
The enrollee or the enrollee's authorized representative may be
required to notify the health plan company, claims
administrator, or utilization review organization as soon after
the beginning of the emergency confinement or emergency
treatment as reasonably possible.
Sec. 26. Minnesota Statutes 1998, section 62M.09,
subdivision 3, is amended to read:
Subd. 3. [PHYSICIAN REVIEWER INVOLVEMENT.] A physician
must review all cases in which the utilization review
organization has concluded that a determination not to certify
for clinical reasons is appropriate. The physician should be
reasonably available by telephone to discuss the determination
with the attending physician health care professional. This
subdivision does not apply to outpatient mental health or
substance abuse services governed by subdivision 3a.
Sec. 27. Minnesota Statutes 1998, section 62M.10,
subdivision 2, is amended to read:
Subd. 2. [REVIEWS DURING NORMAL BUSINESS HOURS.] A
utilization review organization must conduct its telephone
reviews, on-site reviews, and hospital communications during
hospitals' and physicians' reasonable and normal business hours,
unless otherwise mutually agreed.
Sec. 28. Minnesota Statutes 1998, section 62M.10,
subdivision 5, is amended to read:
Subd. 5. [ORAL REQUESTS FOR INFORMATION.] Utilization
review organizations shall orally inform, upon request,
designated hospital personnel or the attending physician health
care professional of the utilization review requirements of the
specific health benefit plan and the general type of criteria
used by the review agent. Utilization review organizations
should also orally inform, upon request, hospitals, physicians,
and other health care professionals a provider of the
operational procedures in order to facilitate the review process.
Sec. 29. Minnesota Statutes 1998, section 62M.10,
subdivision 7, is amended to read:
Subd. 7. [AVAILABILITY OF CRITERIA.] Upon request, a
utilization review organization shall provide to an enrollee or
to an attending physician or a provider the criteria used for a
specific procedure to determine the necessity, appropriateness,
and efficacy of that procedure and identify the database,
professional treatment guideline, or other basis for the
criteria.
Sec. 30. Minnesota Statutes 1998, section 62M.12, is
amended to read:
62M.12 [PROHIBITION OF INAPPROPRIATE INCENTIVES.]
No individual who is performing utilization review may
receive any financial incentive based on the number of denials
of certifications made by such individual, provided that
utilization review organizations may establish medically
appropriate performance standards. This prohibition does not
apply to financial incentives established between health plans
plan companies and their providers.
Sec. 31. Minnesota Statutes 1998, section 62M.15, is
amended to read:
62M.15 [APPLICABILITY OF OTHER CHAPTER REQUIREMENTS.]
The requirements of this chapter regarding the conduct of
utilization review are in addition to any specific requirements
contained in chapter 62A, 62C, 62D, 62Q, 62T, or 72A.
Sec. 32. Minnesota Statutes 1998, section 62Q.106, is
amended to read:
62Q.106 [DISPUTE RESOLUTION BY COMMISSIONER.]
A complainant may at any time submit a complaint to the
appropriate commissioner to investigate. After investigating a
complaint, or reviewing a company's decision, the appropriate
commissioner may order a remedy as authorized under section
62Q.30 or chapter 45, 60A, or 62D.
Sec. 33. Minnesota Statutes 1998, section 62Q.19,
subdivision 5a, is amended to read:
Subd. 5a. [COOPERATION.] Each health plan company and
essential community provider shall cooperate to facilitate the
use of the essential community provider by the high risk and
special needs populations. This includes cooperation on the
submission and processing of claims, sharing of all pertinent
records and data, including performance indicators and specific
outcomes data, and the use of all dispute resolution methods as
defined in section 62Q.11, subdivision 1.
Sec. 34. [62Q.68] [DEFINITIONS.]
Subdivision 1. [APPLICATION.] For purposes of sections
62Q.68 to 62Q.72, the terms defined in this section have the
meanings given them. For purposes of sections 62Q.69 and
62Q.70, the term "health plan company" does not include an
insurance company licensed under chapter 60A to offer, sell, or
issue a policy of accident and sickness insurance as defined in
section 62A.01 or a nonprofit health service plan corporation
regulated under chapter 62C that only provides dental coverage
or vision coverage.
Subd. 2. [COMPLAINT.] "Complaint" means any grievance
against a health plan company that is not the subject of
litigation and that has been submitted by a complainant to a
health plan company regarding the provision of health services
including, but not limited to, the scope of coverage for health
care services; retrospective denials or limitations of payment
for services; eligibility issues; denials, cancellations, or
nonrenewals of coverage; administrative operations; and the
quality, timeliness, and appropriateness of health care services
rendered. If the complaint is from an applicant, the complaint
must relate to the application. If the complaint is from a
former enrollee, the complaint must relate to services received
during the period of time the individual was an enrollee. Any
grievance requiring a medical determination in its resolution
must have the medical determination aspect of the complaint
processed under the appeal procedure described in section 62M.06.
Subd. 3. [COMPLAINANT.] "Complainant" means an enrollee,
applicant, or former enrollee, or anyone acting on behalf of an
enrollee, applicant, or former enrollee who submits a complaint.
Sec. 35. [62Q.69] [COMPLAINT RESOLUTION.]
Subdivision 1. [ESTABLISHMENT.] Each health plan company
must establish and maintain an internal complaint resolution
process that meets the requirements of this section to provide
for the resolution of a complaint initiated by a complainant.
Subd. 2. [PROCEDURES FOR FILING A COMPLAINT.] (a) A
complainant may submit a complaint to a health plan company
either by telephone or in writing. If a complaint is submitted
orally and the resolution of the complaint, as determined by the
complainant, is partially or wholly adverse to the complainant,
or the oral complaint is not resolved to the satisfaction of the
complainant, by the health plan company within ten days of
receiving the complaint, the health plan company must inform the
complainant that the complaint may be submitted in writing. The
health plan company must also offer to provide the complainant
with any assistance needed to submit a written complaint,
including an offer to complete the complaint form for a
complaint that was previously submitted orally and promptly mail
the completed form to the complainant for the complainant's
signature. At the complainant's request, the health plan
company must provide the assistance requested by the
complainant. The complaint form must include the following
information:
(1) the telephone number of the office of health care
consumer assistance, advocacy, and information, and the health
plan company member services or other departments or persons
equipped to advise complainants on complaint resolution;
(2) the address to which the form must be sent;
(3) a description of the health plan company's internal
complaint procedure and the applicable time limits; and
(4) the toll-free telephone number of either the
commissioner of health or commerce and notification that the
complainant has the right to submit the complaint at any time to
the appropriate commissioner for investigation.
(b) Upon receipt of a written complaint, the health plan
company must notify the complainant within ten business days
that the complaint was received, unless the complaint is
resolved to the satisfaction of the complainant within the ten
business days.
(c) Each health plan company must provide, in the member
handbook, subscriber contract, or certification of coverage, a
clear and concise description of how to submit a complaint and a
statement that, upon request, assistance in submitting a written
complaint is available from the health plan company.
Subd. 3. [NOTIFICATION OF COMPLAINT DECISIONS.] (a) The
health plan company must notify the complainant in writing of
its decision and the reasons for it as soon as practical but in
no case later than 30 days after receipt of a written complaint.
If the health plan company cannot make a decision within 30 days
due to circumstances outside the control of the health plan
company, the health plan company may take up to 14 additional
days to notify the complainant of its decision. If the health
plan company takes any additional days beyond the initial 30-day
period to make its decision, it must inform the complainant, in
advance, of the extension and the reasons for the extension.
(b) If the decision is partially or wholly adverse to the
complainant, the notification must inform the complainant of the
right to appeal the decision to the health plan company's
internal appeal process described in section 62Q.70 and the
procedure for initiating an appeal.
(c) The notification must also inform the complainant of
the right to submit the complaint at any time to either the
commissioner of health or commerce for investigation and the
toll-free telephone number of the appropriate commissioner.
Sec. 36. [62Q.70] [APPEAL OF THE COMPLAINT DECISION.]
Subdivision 1. [ESTABLISHMENT.] (a) Each health plan
company shall establish an internal appeal process for reviewing
a health plan company's decision regarding a complaint filed in
accordance with section 62Q.69. The appeal process must meet
the requirements of this section.
(b) The person or persons with authority to resolve or
recommend the resolution of the internal appeal must not be
solely the same person or persons who made the complaint
decision under section 62Q.69.
(c) The internal appeal process must permit the receipt of
testimony, correspondence, explanations, or other information
from the complainant, staff persons, administrators, providers,
or other persons as deemed necessary by the person or persons
investigating or presiding over the appeal.
Subd. 2. [PROCEDURES FOR FILING AN APPEAL.] If a
complainant notifies the health plan company of the
complainant's desire to appeal the health plan company's
decision regarding the complaint through the internal appeal
process, the health plan company must provide the complainant
the option for the appeal to occur either in writing or by
hearing.
Subd. 3. [NOTIFICATION OF APPEAL DECISIONS.] (a) If a
complainant appeals in writing, the health plan company must
give the complainant written notice of the appeal decision and
all key findings within 30 days of the health plan company's
receipt of the complainant's written notice of appeal. If a
complainant appeals by hearing, the health plan company must
give the complainant written notice of the appeal decision and
all key findings within 45 days of the health plan company's
receipt of the complainant's written notice of appeal.
(b) If the appeal decision is partially or wholly adverse
to the complainant, the notice must advise the complainant of
the right to submit the appeal decision to the external review
process described in section 62Q.73 and the procedure for
initiating the external process.
(c) Upon the request of the complainant, the health plan
company must provide the complainant with a complete summary of
the appeal decision.
Sec. 37. [62Q.71] [NOTICE TO ENROLLEES.]
Each health plan company shall provide to enrollees a clear
and concise description of its complaint resolution procedure,
if applicable under section 62Q.68, subdivision 1, and the
procedure used for utilization review as defined under chapter
62M as part of the member handbook, subscriber contract, or
certificate of coverage. If the health plan company does not
issue a member handbook, the health plan company may provide the
description in another written document. The description must
specifically inform enrollees:
(1) how to submit a complaint to the health plan company;
(2) if the health plan includes utilization review
requirements, how to notify the utilization review organization
in a timely manner and how to obtain certification for health
care services;
(3) how to request an appeal either through the procedures
described in sections 62Q.69 and 62Q.70 or through the
procedures described in chapter 62M;
(4) of the right to file a complaint with either the
commissioner of health or commerce at any time during the
complaint and appeal process;
(5) the toll-free telephone number of the appropriate
commissioner;
(6) the telephone number of the office of consumer
assistance, advocacy, and information; and
(7) of the right to obtain an external review under section
62Q.73 and a description of when and how that right may be
exercised.
Sec. 38. [62Q.72] [RECORDKEEPING; REPORTING.]
Subdivision 1. [RECORDKEEPING.] Each health plan company
shall maintain records of all enrollee complaints and their
resolutions. These records shall be retained for five years and
shall be made available to the appropriate commissioner upon
request. An insurance company licensed under chapter 60A may
instead comply with section 72A.20, subdivision 30.
Subd. 2. [REPORTING.] Each health plan company shall
submit to the appropriate commissioner, as part of the company's
annual filing, data on the number and type of complaints that
are not resolved within 30 days, or 30 business days as provided
under section 72A.201, subdivision 4, clause (3), for insurance
companies licensed under chapter 60A. The commissioner shall
also make this information available to the public upon request.
Sec. 39. [62Q.73] [EXTERNAL REVIEW OF ADVERSE
DETERMINATIONS.]
Subdivision 1. [DEFINITION.] For purposes of this section,
adverse determination means:
(1) a complaint decision relating to a health care service
or claim that has been appealed in accordance with section
62Q.70 and the appeal decision is partially or wholly adverse to
the complainant;
(2) any initial determination not to certify that has been
appealed in accordance with section 62M.06 and the appeal did
not reverse the initial determination not to certify; or
(3) a decision relating to a health care service made by a
health plan company licensed under chapter 60A that denies the
service on the basis that the service was not medically
necessary.
An adverse determination does not include complaints relating to
fraudulent marketing practices or agent misrepresentation.
Subd. 2. [EXCEPTION.] (a) This section does not apply to
governmental programs except as permitted under paragraph (b).
For purposes of this subdivision, "governmental programs" means
the prepaid medical assistance program, the MinnesotaCare
program, the prepaid general assistance medical care program,
and the federal Medicare program.
(b) In the course of a recipient's appeal of a medical
determination to the commissioner of human services under
section 256.045, the recipient may request an expert medical
opinion be arranged by the external review entity under contract
to provide independent external reviews under this section. If
such a request is made, the cost of the review shall be paid by
the commissioner of human services. Any medical opinion
obtained under this paragraph shall only be used by a state
human services referee as evidence in the recipient's appeal to
the commissioner of human services under section 256.045.
(c) Nothing in this subdivision shall be construed to limit
or restrict the appeal rights provided in section 256.045 for
governmental program recipients.
Subd. 3. [RIGHT TO EXTERNAL REVIEW.] (a) Any enrollee or
anyone acting on behalf of an enrollee who has received an
adverse determination may submit a written request for an
external review of the adverse determination, if applicable
under section 62Q.68, subdivision 1, or 62M.06, to the
commissioner of health if the request involves a health plan
company regulated by that commissioner or to the commissioner of
commerce if the request involves a health plan company regulated
by that commissioner. The written request must be accompanied
by a filing fee of $25. The fee may be waived by the
commissioner of health or commerce in cases of financial
hardship.
(b) Nothing in this section requires the commissioner of
health or commerce to independently investigate an adverse
determination referred for independent external review.
(c) If an enrollee requests an external review, the health
plan company must participate in the external review. The cost
of the external review in excess of the filing fee described in
paragraph (a) shall be borne by the health plan company.
Subd. 4. [CONTRACT.] Pursuant to a request for proposal,
the commissioner of administration, in consultation with the
commissioners of health and commerce, shall contract with an
organization or business entity to provide independent external
reviews of all adverse determinations submitted for external
review. The contract shall ensure that the fees for services
rendered in connection with the reviews be reasonable.
Subd. 5. [CRITERIA.] (a) The request for proposal must
require that the entity demonstrate:
(1) no conflicts of interest in that it is not owned, a
subsidiary of, or affiliated with a health plan company or
utilization review organization;
(2) an expertise in dispute resolution;
(3) an expertise in health related law;
(4) an ability to conduct reviews using a variety of
alternative dispute resolution procedures depending upon the
nature of the dispute;
(5) an ability to provide data to the commissioners of
health and commerce on reviews conducted; and
(6) an ability to ensure confidentiality of medical records
and other enrollee information.
(b) The commissioner of administration shall take into
consideration, in awarding the contract according to subdivision
4, any national accreditation standards that pertain to an
external review entity.
Subd. 6. [PROCESS.] (a) Upon receiving a request for an
external review, the external review entity must provide
immediate notice of the review to the enrollee and to the health
plan company. Within ten business days of receiving notice of
the review the health plan company and the enrollee must provide
the external review entity with any information that they wish
to be considered. Each party shall be provided an opportunity
to present its version of the facts and arguments. An enrollee
may be assisted or represented by a person of the enrollee's
choice.
(b) As part of the external review process, any aspect of
an external review involving a medical determination must be
performed by a health care professional with expertise in the
medical issue being reviewed.
(c) An external review shall be made as soon as practical
but in no case later than 40 days after receiving the request
for an external review and must promptly send written notice of
the decision and the reasons for it to the enrollee, the health
plan company, and to the commissioner who is responsible for
regulating the health plan company.
Subd. 7. [STANDARDS OF REVIEW.] (a) For an external review
of any issue in an adverse determination that does not require a
medical necessity determination, the external review must be
based on whether the adverse determination was in compliance
with the enrollee's health benefit plan.
(b) For an external review of any issue in an adverse
determination by a health plan company licensed under chapter
62D that requires a medical necessity determination, the
external review must determine whether the adverse determination
was consistent with the definition of medically necessary care
in Minnesota Rules, part 4685.0100, subpart 9b.
(c) For an external review of any issue in an adverse
determination by a health plan company, other than a health plan
company licensed under chapter 62D, that requires a medical
necessity determination, the external review must determine
whether the adverse determination was consistent with the
definition of medically necessary care in section 62Q.53,
subdivision 2.
Subd. 8. [EFFECTS OF EXTERNAL REVIEW.] A decision rendered
under this section shall be nonbinding on the enrollee and
binding on the health plan company. The health plan company may
seek judicial review of the decision on the grounds that the
decision was arbitrary and capricious or involved an abuse of
discretion.
Subd. 9. [IMMUNITY FROM CIVIL LIABILITY.] A person who
participates in an external review by investigating, reviewing
materials, providing technical expertise, or rendering a
decision shall not be civilly liable for any action that is
taken in good faith, that is within the scope of the person's
duties, and that does not constitute willful or reckless
misconduct.
Subd. 10. [DATA REPORTING.] The commissioners shall make
available to the public, upon request, summary data on the
decisions rendered under this section, including the number of
reviews heard and decided and the final outcomes. Any data
released to the public must not individually identify the
enrollee initiating the request for external review.
Sec. 40. Minnesota Statutes 1998, section 62T.04, is
amended to read:
62T.04 [COMPLAINT SYSTEM.]
Accountable provider networks must establish and maintain
an enrollee complaint system as required under section
62Q.105 sections 62Q.68 to 62Q.72. The accountable provider
network may contract with the health care purchasing alliance or
a vendor for operation of this system.
Sec. 41. Minnesota Statutes 1998, section 72A.201,
subdivision 4a, is amended to read:
Subd. 4a. [STANDARDS FOR PREAUTHORIZATION APPROVAL.] If a
policy of accident and sickness insurance or a subscriber
contract requires preauthorization approval for any nonemergency
services or benefits, the decision to approve or disapprove the
requested services or benefits must be communicated to the
insured or the insured's health care provider within ten
business days of the preauthorization request provided that all
information reasonably necessary to make a decision on the
request has been made available to the insurer processed in
accordance with section 62M.07.
Sec. 42. Minnesota Statutes 1998, section 256B.692,
subdivision 2, is amended to read:
Subd. 2. [DUTIES OF THE COMMISSIONER OF HEALTH.]
Notwithstanding chapters 62D and 62N, a county that elects to
purchase medical assistance and general assistance medical care
in return for a fixed sum without regard to the frequency or
extent of services furnished to any particular enrollee is not
required to obtain a certificate of authority under chapter 62D
or 62N. A county that elects to purchase medical assistance and
general assistance medical care services under this section must
satisfy the commissioner of health that the requirements of
chapter 62D, applicable to health maintenance organizations, or
chapter 62N, applicable to community integrated service
networks, will be met. A county must also assure the
commissioner of health that the requirements of sections
62J.041; 62J.48; 62J.71 to 62J.73; 62M.01 to 62M.16; all
applicable provisions of chapter 62Q, including sections 62Q.07;
62Q.075; 62Q.105; 62Q.1055; 62Q.106; 62Q.11; 62Q.12; 62Q.135;
62Q.14; 62Q.145; 62Q.19; 62Q.23, paragraph (c); 62Q.30; 62Q.43;
62Q.47; 62Q.50; 62Q.52 to 62Q.56; 62Q.58; 62Q.64; 62Q.68 to
62Q.72; and 72A.201 will be met. All enforcement and rulemaking
powers available under chapters 62D, 62J, 62M, 62N, and 62Q are
hereby granted to the commissioner of health with respect to
counties that purchase medical assistance and general assistance
medical care services under this section.
Sec. 43. [REPEALER.]
(a) Minnesota Statutes 1998, section 62D.11, subdivisions
1b and 2, are repealed.
(b) Minnesota Statutes 1998, sections 62Q.105; 62Q.11; and
62Q.30, are repealed.
(c) Minnesota Rules, parts 4685.0100, subparts 4 and 4a;
and 4685.1700, are repealed.
(d) Minnesota Rules, part 4685.1010, subpart 3, is repealed.
Sec. 44. [EFFECTIVE DATE.]
Sections 1, 3 to 42, and 43, paragraphs (a) and (c), are
effective April 1, 2000, and apply to contracts issued or
renewed on or after that date. Upon request, the commissioner
of health or commerce shall grant an extension of up to three
months to any health plan company or utilization review
organization that is unable to comply with sections 1, 3 to 42,
and 43, paragraphs (a) and (c) by April 1, 2000, due to
circumstances beyond the control of the health plan company or
utilization review organization.
Section 43, paragraph (b), is effective July 1, 1999.
Sections 2 and 43, paragraph (d), are effective January 1,
2000, and apply to contracts issued or renewed on or after that
date.
Presented to the governor May 24, 1999
Signed by the governor May 25, 1999, 11:50 a.m.
Official Publication of the State of Minnesota
Revisor of Statutes