1.1                          A bill for an act 
  1.2             relating to health; establishing a uniform complaint 
  1.3             resolution process for health plan companies; 
  1.4             establishing an external appeal process; amending 
  1.5             Minnesota Statutes 1998, sections 62D.11, subdivision 
  1.6             1; 62M.01; 62M.02, subdivisions 3, 4, 5, 6, 7, 9, 10, 
  1.7             11, 12, 17, 20, 21, and by adding a subdivision; 
  1.8             62M.03, subdivisions 1 and 3; 62M.04, subdivisions 1, 
  1.9             2, 3, and 4; 62M.05; 62M.06; 62M.07; 62M.09, 
  1.10            subdivision 3; 62M.10, subdivisions 2, 5, and 7; 
  1.11            62M.12; 62M.15; 62Q.106; 62Q.19, subdivision 5a; 
  1.12            62T.04; 72A.201, subdivisions 4 and 4a; and 256B.692, 
  1.13            subdivision 2; proposing coding for new law in 
  1.14            Minnesota Statutes, chapter 62Q; repealing Minnesota 
  1.15            Statutes 1998, sections 62D.11, subdivisions 1b and 2; 
  1.16            62Q.105; 62Q.11; and 62Q.30; Minnesota Rules, parts 
  1.17            4685.0100, subparts 4 and 4a; and 4685.1700. 
  1.18  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.19     Section 1.  Minnesota Statutes 1998, section 62D.11, 
  1.20  subdivision 1, is amended to read: 
  1.21     Subdivision 1.  [ENROLLEE COMPLAINT SYSTEM.] Every health 
  1.22  maintenance organization shall establish and maintain a 
  1.23  complaint system, as required under ~~section 62Q.105~~ sections 
  1.24  62Q.68 to 62Q.72 to provide reasonable procedures for the 
  1.25  resolution of written complaints initiated by or on behalf of 
  1.26  enrollees concerning the provision of health care 
  1.27  services.  ~~"Provision of health services" includes, but is not~~ 
  1.28  ~~limited to, questions of the scope of coverage, quality of care,~~ 
  1.29  ~~and administrative operations.  The health maintenance~~ 
  1.30  ~~organization must inform enrollees that they may choose to use~~ 
  1.31  ~~arbitration to appeal a health maintenance organization's~~ 
  2.1   ~~internal appeal decision.  The health maintenance organization~~ 
  2.2   ~~must also inform enrollees that they have the right to use~~ 
  2.3   ~~arbitration to appeal a health maintenance organization's~~ 
  2.4   ~~internal appeal decision not to certify an admission, procedure,~~ 
  2.5   ~~service, or extension of stay under section 62M.06.  If an~~ 
  2.6   ~~enrollee chooses to use arbitration, the health maintenance~~ 
  2.7   ~~organization must participate.~~ 
  2.8      Sec. 2.  Minnesota Statutes 1998, section 62M.01, is 
  2.9   amended to read: 
  2.10     62M.01 [CITATION, JURISDICTION, AND SCOPE.] 
  2.11     Subdivision 1.  [POPULAR NAME.] Sections 62M.01 to 62M.16 
  2.12  may be cited as the "Minnesota Utilization Review Act of 1992." 
  2.13     Subd. 2.  [JURISDICTION.] Sections 62M.01 to 62M.16 apply 
  2.14  to any insurance company licensed under chapter 60A to offer, 
  2.15  sell, or issue a policy of accident and sickness insurance as 
  2.16  defined in section 62A.01; a health service plan licensed under 
  2.17  chapter 62C; a health maintenance organization licensed under 
  2.18  chapter 62D; a community integrated service network licensed 
  2.19  under chapter 62N; an accountable provider network operating 
  2.20  under chapter 62T; a fraternal benefit society operating under 
  2.21  chapter 64B; a joint self-insurance employee health plan 
  2.22  operating under chapter 62H; a multiple employer welfare 
  2.23  arrangement, as defined in section 3 of the Employee Retirement 
  2.24  Income Security Act of 1974 (ERISA), United States Code, title 
  2.25  29, section 1103, as amended; a third party administrator 
  2.26  licensed under section 60A.23, subdivision 8, that provides 
  2.27  utilization review services for the administration of benefits 
  2.28  under a health benefit plan as defined in section 62M.02; or any 
  2.29  entity performing utilization review on behalf of a business 
  2.30  entity in this state pursuant to a health benefit plan covering 
  2.31  a Minnesota resident. 
  2.32     Subd. 3.  [SCOPE.] ~~Sections 62M.02, 62M.07, and 62M.09,~~ 
  2.33  ~~subdivision 4, apply to prior authorization of services.~~  
  2.34  Nothing in sections 62M.01 to 62M.16 applies to review of claims 
  2.35  after submission to determine eligibility for benefits under a 
  2.36  health benefit plan.  The appeal procedure described in section 
  3.1   62M.06 applies to any complaint as defined under section 62Q.68, 
  3.2   subdivision 2, that requires a medical determination in its 
  3.3   resolution.  
  3.4      Sec. 3.  Minnesota Statutes 1998, section 62M.02, 
  3.5   subdivision 3, is amended to read: 
  3.6      Subd. 3.  [ATTENDING DENTIST.] "Attending dentist" means 
  3.7   the dentist with primary responsibility for the dental care 
  3.8   provided to ~~a patient~~ an enrollee. 
  3.9      Sec. 4.  Minnesota Statutes 1998, section 62M.02, 
  3.10  subdivision 4, is amended to read: 
  3.11     Subd. 4.  [ATTENDING ~~PHYSICIAN~~ HEALTH CARE PROFESSIONAL.] 
  3.12  "Attending ~~physician~~ health care professional" means 
  3.13  the ~~physician~~ health care professional with primary 
  3.14  responsibility for the care provided to ~~a patient~~ an enrollee ~~in~~ 
  3.15  ~~a hospital or other health care facility~~. 
  3.16     Sec. 5.  Minnesota Statutes 1998, section 62M.02, 
  3.17  subdivision 5, is amended to read: 
  3.18     Subd. 5.  [CERTIFICATION.] "Certification" means a 
  3.19  determination by a utilization review organization that an 
  3.20  admission, extension of stay, or other health care service has 
  3.21  been reviewed and that it, based on the information provided, 
  3.22  meets the utilization review requirements of the applicable 
  3.23  health plan and the health ~~carrier~~ plan company will then pay 
  3.24  for the covered benefit, provided the preexisting limitation 
  3.25  provisions, the general exclusion provisions, and any 
  3.26  deductible, copayment, coinsurance, or other policy requirements 
  3.27  have been met. 
  3.28     Sec. 6.  Minnesota Statutes 1998, section 62M.02, 
  3.29  subdivision 6, is amended to read: 
  3.30     Subd. 6.  [CLAIMS ADMINISTRATOR.] "Claims administrator" 
  3.31  means an entity that reviews and determines whether to pay 
  3.32  claims to enrollees~~, physicians, hospitals, or others~~ or 
  3.33  providers based on the contract provisions of the health plan 
  3.34  contract.  Claims administrators may include insurance companies 
  3.35  licensed under chapter 60A to offer, sell, or issue a policy of 
  3.36  accident and sickness insurance as defined in section 62A.01; a 
  4.1   health service plan licensed under chapter 62C; a health 
  4.2   maintenance organization licensed under chapter 62D; a community 
  4.3   integrated service network licensed under chapter 62N; an 
  4.4   accountable provider network operating under chapter 62T; a 
  4.5   fraternal benefit society operating under chapter 64B; a 
  4.6   multiple employer welfare arrangement, as defined in section 3 
  4.7   of the Employee Retirement Income Security Act of 1974 (ERISA), 
  4.8   United States Code, title 29, section 1103, as amended. 
  4.9      Sec. 7.  Minnesota Statutes 1998, section 62M.02, 
  4.10  subdivision 7, is amended to read: 
  4.11     Subd. 7.  [CLAIMANT.] "Claimant" means the enrollee ~~or~~ 
  4.12  ~~covered person~~ who files a claim for benefits or a provider of 
  4.13  services who, pursuant to a contract with a claims 
  4.14  administrator, files a claim on behalf of an enrollee or covered 
  4.15  person. 
  4.16     Sec. 8.  Minnesota Statutes 1998, section 62M.02, 
  4.17  subdivision 9, is amended to read: 
  4.18     Subd. 9.  [CONCURRENT REVIEW.] "Concurrent review" means 
  4.19  utilization review conducted during ~~a patient's~~ an enrollee's 
  4.20  hospital stay or course of treatment and has the same meaning as 
  4.21  continued stay review. 
  4.22     Sec. 9.  Minnesota Statutes 1998, section 62M.02, 
  4.23  subdivision 10, is amended to read: 
  4.24     Subd. 10.  [DISCHARGE PLANNING.] "Discharge planning" means 
  4.25  the process that assesses ~~a patient's~~ an enrollee's need for 
  4.26  treatment after hospitalization in order to help arrange for the 
  4.27  necessary services and resources to effect an appropriate and 
  4.28  timely discharge. 
  4.29     Sec. 10.  Minnesota Statutes 1998, section 62M.02, 
  4.30  subdivision 11, is amended to read: 
  4.31     Subd. 11.  [ENROLLEE.] "Enrollee" means an individual ~~who~~ 
  4.32  ~~has elected to contract for, or participate in, a health benefit~~ 
  4.33  ~~plan for enrollee coverage or for dependent coverage~~ covered by 
  4.34  a health benefit plan and includes an insured policyholder, 
  4.35  subscriber contract holder, member, covered person, or 
  4.36  certificate holder. 
  5.1      Sec. 11.  Minnesota Statutes 1998, section 62M.02, 
  5.2   subdivision 12, is amended to read: 
  5.3      Subd. 12.  [HEALTH BENEFIT PLAN.] "Health benefit plan" 
  5.4   means a policy, contract, or certificate issued by a health 
  5.5   ~~carrier to an employer or individual~~ plan company for the 
  5.6   coverage of medical, dental, or hospital benefits.  A health 
  5.7   benefit plan does not include coverage that is: 
  5.8      (1) limited to disability or income protection coverage; 
  5.9      (2) automobile medical payment coverage; 
  5.10     (3) supplemental to liability insurance; 
  5.11     (4) designed solely to provide payments on a per diem, 
  5.12  fixed indemnity, or nonexpense incurred basis; 
  5.13     (5) credit accident and health insurance issued under 
  5.14  chapter 62B; 
  5.15     (6) blanket accident and sickness insurance as defined in 
  5.16  section 62A.11; 
  5.17     (7) accident only coverage issued by a licensed and tested 
  5.18  insurance agent; or 
  5.19     (8) workers' compensation. 
  5.20     Sec. 12.  Minnesota Statutes 1998, section 62M.02, is 
  5.21  amended by adding a subdivision to read: 
  5.22     Subd. 12a.  [HEALTH PLAN COMPANY.] "Health plan company" 
  5.23  means a health plan company as defined in section 62Q.01, 
  5.24  subdivision 4, and includes an accountable provider network 
  5.25  operating under chapter 62T. 
  5.26     Sec. 13.  Minnesota Statutes 1998, section 62M.02, 
  5.27  subdivision 17, is amended to read: 
  5.28     Subd. 17.  [PROVIDER.] "Provider" means a licensed health 
  5.29  care facility, physician, or other health care professional that 
  5.30  delivers health care services to an enrollee ~~or covered person~~. 
  5.31     Sec. 14. Minnesota Statutes 1998, section 62M.02, 
  5.32  subdivision 20, is amended to read: 
  5.33     Subd. 20.  [UTILIZATION REVIEW.] "Utilization review" means 
  5.34  the evaluation of the necessity, appropriateness, and efficacy 
  5.35  of the use of health care services, procedures, and facilities, 
  5.36  by a person or entity other than the attending ~~physician~~ health 
  6.1   care professional, for the purpose of determining the medical 
  6.2   necessity of the service or admission.  Utilization review also 
  6.3   includes review conducted after the admission of the enrollee.  
  6.4   It includes situations where the enrollee is unconscious or 
  6.5   otherwise unable to provide advance notification.  ~~Utilization~~ 
  6.6   ~~review does not include the imposition of a requirement that~~ 
  6.7   ~~services be received by or upon referral from a participating~~ 
  6.8   ~~provider.~~ 
  6.9      Sec. 15.  Minnesota Statutes 1998, section 62M.02, 
  6.10  subdivision 21, is amended to read: 
  6.11     Subd. 21.  [UTILIZATION REVIEW ORGANIZATION.] "Utilization 
  6.12  review organization" means an entity including but not limited 
  6.13  to an insurance company licensed under chapter 60A to offer, 
  6.14  sell, or issue a policy of accident and sickness insurance as 
  6.15  defined in section 62A.01; a health service plan licensed under 
  6.16  chapter 62C; a health maintenance organization licensed under 
  6.17  chapter 62D; a community integrated service network licensed 
  6.18  under chapter 62N; an accountable provider network operating 
  6.19  under chapter 62T; a fraternal benefit society operating under 
  6.20  chapter 64B; a joint self-insurance employee health plan 
  6.21  operating under chapter 62H; a multiple employer welfare 
  6.22  arrangement, as defined in section 3 of the Employee Retirement 
  6.23  Income Security Act of 1974 (ERISA), United States Code, title 
  6.24  29, section 1103, as amended; a third party administrator 
  6.25  licensed under section 60A.23, subdivision 8, which conducts 
  6.26  utilization review and determines certification of an admission, 
  6.27  extension of stay, or other health care services for a Minnesota 
  6.28  resident; or any entity performing utilization review that is 
  6.29  affiliated with, under contract with, or conducting utilization 
  6.30  review on behalf of, a business entity in this state. 
  6.31     Sec. 16.  Minnesota Statutes 1998, section 62M.03, 
  6.32  subdivision 1, is amended to read: 
  6.33     Subdivision 1.  [LICENSED UTILIZATION REVIEW ORGANIZATION.] 
  6.34  Beginning January 1, 1993, any organization that meets the 
  6.35  definition of utilization review organization in section 62M.02, 
  6.36  subdivision 21, must be licensed under chapter 60A, 62C, 62D, 
  7.1   62N, 62T, or 64B, or registered under this chapter and must 
  7.2   comply with sections 62M.01 to 62M.16 and section 72A.201, 
  7.3   subdivisions 8 and 8a.  Each licensed community integrated 
  7.4   service network or health maintenance organization that has an 
  7.5   employed staff model of providing health care services shall 
  7.6   comply with sections 62M.01 to 62M.16 and section 72A.201, 
  7.7   subdivisions 8 and 8a, for any services provided by providers 
  7.8   under contract. 
  7.9      Sec. 17.  Minnesota Statutes 1998, section 62M.03, 
  7.10  subdivision 3, is amended to read: 
  7.11     Subd. 3.  [PENALTIES AND ENFORCEMENTS.] If a utilization 
  7.12  review organization fails to comply with sections 62M.01 to 
  7.13  62M.16, the organization may not provide utilization review 
  7.14  services for any Minnesota resident.  The commissioner of 
  7.15  commerce may issue a cease and desist order under section 
  7.16  45.027, subdivision 5, to enforce this provision.  The cease and 
  7.17  desist order is subject to appeal under chapter 14.  A 
  7.18  nonlicensed utilization review organization that fails to comply 
  7.19  with the provisions of sections 62M.01 to 62M.16 is subject to 
  7.20  all applicable penalty and enforcement provisions of section 
  7.21  72A.201.  Each utilization review organization licensed under 
  7.22  chapter 60A, 62C, 62D, 62N, 62T, or 64B shall comply with 
  7.23  sections 62M.01 to 62M.16 as a condition of licensure. 
  7.24     Sec. 18.  Minnesota Statutes 1998, section 62M.04, 
  7.25  subdivision 1, is amended to read: 
  7.26     Subdivision 1.  [RESPONSIBILITY FOR OBTAINING 
  7.27  CERTIFICATION.] A health benefit plan that includes utilization 
  7.28  review requirements must specify the process for notifying the 
  7.29  utilization review organization in a timely manner and obtaining 
  7.30  certification for health care services.  Each health plan 
  7.31  company must provide a clear and concise description of this 
  7.32  process to an enrollee as part of the policy, subscriber 
  7.33  contract, or certificate of coverage.  In addition to the 
  7.34  enrollee, the utilization review organization must allow any 
  7.35  ~~licensed hospital, physician or the physician's~~ provider or 
  7.36  provider's designee, or responsible patient representative, 
  8.1   including a family member, to fulfill the obligations under the 
  8.2   health plan. 
  8.3      A claims administrator that contracts directly with 
  8.4   providers for the provision of health care services to enrollees 
  8.5   may, through contract, require the provider to notify the review 
  8.6   organization in a timely manner and obtain certification for 
  8.7   health care services. 
  8.8      Sec. 19.  Minnesota Statutes 1998, section 62M.04, 
  8.9   subdivision 2, is amended to read: 
  8.10     Subd. 2.  [INFORMATION UPON WHICH UTILIZATION REVIEW IS 
  8.11  CONDUCTED.] If the utilization review organization is conducting 
  8.12  routine prospective and concurrent utilization review, 
  8.13  utilization review organizations must collect only the 
  8.14  information necessary to certify the admission, procedure of 
  8.15  treatment, and length of stay. 
  8.16     (a) Utilization review organizations may request, but may 
  8.17  not require~~, hospitals, physicians, or other~~ providers to supply 
  8.18  numerically encoded diagnoses or procedures as part of the 
  8.19  certification process. 
  8.20     (b) Utilization review organizations must not routinely 
  8.21  request copies of medical records for all patients reviewed.  In 
  8.22  performing prospective and concurrent review, copies of the 
  8.23  pertinent portion of the medical record should be required only 
  8.24  when a difficulty develops in certifying the medical necessity 
  8.25  or appropriateness of the admission or extension of stay. 
  8.26     (c) Utilization review organizations may request copies of 
  8.27  medical records retrospectively for a number of purposes, 
  8.28  including auditing the services provided, quality assurance 
  8.29  review, ensuring compliance with the terms of either the health 
  8.30  benefit plan or the provider contract, and compliance with 
  8.31  utilization review activities.  Except for reviewing medical 
  8.32  records associated with an appeal or with an investigation or 
  8.33  audit of data discrepancies, ~~health care~~ providers must be 
  8.34  reimbursed for the reasonable costs of duplicating records 
  8.35  requested by the utilization review organization for 
  8.36  retrospective review unless otherwise provided under the terms 
  9.1   of the provider contract. 
  9.2      Sec. 20.  Minnesota Statutes 1998, section 62M.04, 
  9.3   subdivision 3, is amended to read: 
  9.4      Subd. 3.  [DATA ELEMENTS.] Except as otherwise provided in 
  9.5   sections 62M.01 to 62M.16, for purposes of certification a 
  9.6   utilization review organization must limit its data requirements 
  9.7   to the following elements: 
  9.8      (a) Patient information that includes the following: 
  9.9      (1) name; 
  9.10     (2) address; 
  9.11     (3) date of birth; 
  9.12     (4) sex; 
  9.13     (5) social security number or patient identification 
  9.14  number; 
  9.15     (6) name of health ~~carrier~~ plan company or health plan; and 
  9.16     (7) plan identification number. 
  9.17     (b) Enrollee information that includes the following: 
  9.18     (1) name; 
  9.19     (2) address; 
  9.20     (3) social security number or employee identification 
  9.21  number; 
  9.22     (4) relation to patient; 
  9.23     (5) employer; 
  9.24     (6) health benefit plan; 
  9.25     (7) group number or plan identification number; and 
  9.26     (8) availability of other coverage. 
  9.27     (c) Attending ~~physician or provider~~ health care 
  9.28  professional information that includes the following: 
  9.29     (1) name; 
  9.30     (2) address; 
  9.31     (3) telephone numbers; 
  9.32     (4) degree and license; 
  9.33     (5) specialty or board certification status; and 
  9.34     (6) tax identification number or other identification 
  9.35  number. 
  9.36     (d) Diagnosis and treatment information that includes the 
 10.1   following: 
 10.2      (1) primary diagnosis with associated ICD or DSM coding, if 
 10.3   available; 
 10.4      (2) secondary diagnosis with associated ICD or DSM coding, 
 10.5   if available; 
 10.6      (3) tertiary diagnoses with associated ICD or DSM coding, 
 10.7   if available; 
 10.8      (4) proposed procedures or treatments with ICD or 
 10.9   associated CPT codes, if available; 
 10.10     (5) surgical assistant requirement; 
 10.11     (6) anesthesia requirement; 
 10.12     (7) proposed admission or service dates; 
 10.13     (8) proposed procedure date; and 
 10.14     (9) proposed length of stay. 
 10.15     (e) Clinical information that includes the following: 
 10.16     (1) support and documentation of appropriateness and level 
 10.17  of service proposed; and 
 10.18     (2) identification of contact person for detailed clinical 
 10.19  information. 
 10.20     (f) Facility information that includes the following:  
 10.21     (1) type; 
 10.22     (2) licensure and certification status and DRG exempt 
 10.23  status; 
 10.24     (3) name; 
 10.25     (4) address; 
 10.26     (5) telephone number; and 
 10.27     (6) tax identification number or other identification 
 10.28  number. 
 10.29     (g) Concurrent or continued stay review information that 
 10.30  includes the following: 
 10.31     (1) additional days, services, or procedures proposed; 
 10.32     (2) reasons for extension, including clinical information 
 10.33  sufficient for support of appropriateness and level of service 
 10.34  proposed; and 
 10.35     (3) diagnosis status. 
 10.36     (h) For admissions to facilities other than acute medical 
 11.1   or surgical hospitals, additional information that includes the 
 11.2   following: 
 11.3      (1) history of present illness; 
 11.4      (2) patient treatment plan and goals; 
 11.5      (3) prognosis; 
 11.6      (4) staff qualifications; and 
 11.7      (5) 24-hour availability of staff. 
 11.8      Additional information may be required for other specific 
 11.9   review functions such as discharge planning or catastrophic case 
 11.10  management.  Second opinion information may also be required, 
 11.11  when applicable, to support benefit plan requirements. 
 11.12     Sec. 21.  Minnesota Statutes 1998, section 62M.04, 
 11.13  subdivision 4, is amended to read: 
 11.14     Subd. 4.  [ADDITIONAL INFORMATION.] A utilization review 
 11.15  organization may request information in addition to that 
 11.16  described in subdivision 3 when there is significant lack of 
 11.17  agreement between the utilization review organization and the 
 11.18  ~~health care~~ provider regarding the appropriateness of 
 11.19  certification during the review or appeal process.  For purposes 
 11.20  of this subdivision, "significant lack of agreement" means that 
 11.21  the utilization review organization has: 
 11.22     (1) tentatively determined through its professional staff 
 11.23  that a service cannot be certified; 
 11.24     (2) referred the case to a physician for review; and 
 11.25     (3) talked to or attempted to talk to the attending 
 11.26  ~~physician~~ health care professional for further information. 
 11.27     Nothing in sections 62M.01 to 62M.16 prohibits a 
 11.28  utilization review organization from requiring submission of 
 11.29  data necessary to comply with the quality assurance and 
 11.30  utilization review requirements of chapter 62D or other 
 11.31  appropriate data or outcome analyses. 
 11.32     Sec. 22.  Minnesota Statutes 1998, section 62M.05, is 
 11.33  amended to read: 
 11.34     62M.05 [PROCEDURES FOR REVIEW DETERMINATION.] 
 11.35     Subdivision 1.  [WRITTEN PROCEDURES.] A utilization review 
 11.36  organization must have written procedures to ensure that reviews 
 12.1   are conducted in accordance with the requirements of this 
 12.2   chapter ~~and section 72A.201, subdivision 4a~~. 
 12.3      Subd. 2.  [CONCURRENT REVIEW.] A utilization review 
 12.4   organization may review ongoing inpatient stays based on the 
 12.5   severity or complexity of the ~~patient's~~ enrollee's condition or 
 12.6   on necessary treatment or discharge planning activities.  Such 
 12.7   review must not be consistently conducted on a daily basis. 
 12.8      Subd. 3.  [NOTIFICATION OF DETERMINATIONS.] A utilization 
 12.9   review organization must have written procedures for providing 
 12.10  notification of its determinations on all certifications in 
 12.11  accordance with ~~the following:~~ this section. 
 12.12     Subd. 3a.  [STANDARD REVIEW DETERMINATION.] (a) 
 12.13  Notwithstanding subdivision 3b, an initial determination on all 
 12.14  requests for utilization review must be communicated to the 
 12.15  provider and enrollee in accordance with this subdivision within 
 12.16  ten business days of the request, provided that all information 
 12.17  reasonably necessary to make a decision on the request has been 
 12.18  made available to the utilization review organization.  
 12.19     (b) When an initial determination is made to certify, 
 12.20  notification must be provided promptly by telephone to the 
 12.21  provider.  The utilization review organization shall send 
 12.22  written notification to the ~~hospital, attending physician, or~~ 
 12.23  ~~applicable service provider within ten business days of the~~ 
 12.24  ~~determination in accordance with section 72A.201, subdivision~~ 
 12.25  ~~4a,~~ provider or shall maintain an audit trail of the 
 12.26  determination and telephone notification.  For purposes of this 
 12.27  subdivision, "audit trail" includes documentation of the 
 12.28  telephone notification, including the date; the name of the 
 12.29  person spoken to; the enrollee ~~or patient~~; the service, 
 12.30  procedure, or admission certified; and the date of the service, 
 12.31  procedure, or admission.  If the utilization review organization 
 12.32  indicates certification by use of a number, the number must be 
 12.33  called the "certification number." 
 12.34     ~~(b)~~ (c) When ~~a~~ an initial determination is made not to 
 12.35  certify ~~a hospital or surgical facility admission or extension~~ 
 12.36  ~~of a hospital stay, or other service requiring review~~ 
 13.1   ~~determination~~, notification must be provided by telephone within 
 13.2   one working day after making the ~~decision~~ determination to the 
 13.3   attending ~~physician~~ health care professional and hospital ~~must~~ 
 13.4   ~~be notified by telephone~~ and a written notification must be sent 
 13.5   to the hospital, attending ~~physician~~ health care professional, 
 13.6   and enrollee ~~or patient~~.  The written notification must include 
 13.7   the principal reason or reasons for the determination and the 
 13.8   process for initiating an appeal of the determination.  Upon 
 13.9   request, the utilization review organization shall provide 
 13.10  the ~~attending physician or~~ provider or enrollee with the 
 13.11  criteria used to determine the necessity, appropriateness, and 
 13.12  efficacy of the health care service and identify the database, 
 13.13  professional treatment parameter, or other basis for the 
 13.14  criteria.  Reasons for a determination not to certify may 
 13.15  include, among other things, the lack of adequate information to 
 13.16  certify after a reasonable attempt has been made to contact 
 13.17  the ~~attending physician~~ provider or enrollee. 
 13.18     (d) When an initial determination is made not to certify, 
 13.19  the written notification must inform the enrollee and the 
 13.20  attending health care professional of the right to submit an 
 13.21  appeal to either:  
 13.22     (1) the external appeal process described in section 62Q.73 
 13.23  and the procedure for initiating the external process; or 
 13.24     (2) the internal appeal process described in section 62M.03 
 13.25  and the procedure for initiating the internal appeal. 
 13.26     Subd. 3b.  [EXPEDITED REVIEW DETERMINATION.] (a) An 
 13.27  expedited initial determination must be utilized if the 
 13.28  attending health care professional believes that an expedited 
 13.29  determination is warranted. 
 13.30     (b) Notification of an expedited initial determination to 
 13.31  either certify or not to certify must be provided to the 
 13.32  hospital, the attending health care professional, and enrollee 
 13.33  as expeditiously as the enrollee's medical condition requires, 
 13.34  but no later than 72 hours from the initial request.  When an 
 13.35  expedited initial determination is made not to certify, the 
 13.36  utilization review organization must also notify the enrollee 
 14.1   and the attending health care professional of the right to 
 14.2   submit an appeal to either:  
 14.3      (1) the external appeal process described in section 62Q.73 
 14.4   and the procedure for initiating the external process; or 
 14.5      (2) the expedited internal appeal as described in section 
 14.6   62M.06 and the procedure for initiating an internal expedited 
 14.7   appeal. 
 14.8      Subd. 4.  [FAILURE TO PROVIDE NECESSARY INFORMATION.] A 
 14.9   utilization review organization must have written procedures to 
 14.10  address the failure of a ~~health care~~ provider~~, patient, or~~ 
 14.11  ~~representative of either~~ or enrollee to provide the necessary 
 14.12  information for review.  If the ~~patient~~ enrollee or provider 
 14.13  will not release the necessary information to the utilization 
 14.14  review organization, the utilization review organization may 
 14.15  deny certification in accordance with its own policy or the 
 14.16  policy described in the health benefit plan. 
 14.17     Subd. 5.  [NOTIFICATION TO CLAIMS ADMINISTRATOR.] If the 
 14.18  utilization review organization and the claims administrator are 
 14.19  separate entities, the utilization review organization must 
 14.20  forward, electronically or in writing, a notification of 
 14.21  certification or determination not to certify to the appropriate 
 14.22  claims administrator for the health benefit plan. 
 14.23     Sec. 23.  Minnesota Statutes 1998, section 62M.06, is 
 14.24  amended to read: 
 14.25     62M.06 [APPEALS OF DETERMINATIONS NOT TO CERTIFY.] 
 14.26     Subdivision 1.  [PROCEDURES FOR APPEAL.] A utilization 
 14.27  review organization must have written procedures for appeals of 
 14.28  determinations not to certify ~~an admission, procedure, service,~~ 
 14.29  ~~or extension of stay~~.  The right to appeal must be available to 
 14.30  the enrollee ~~or designee~~ and to the attending ~~physician~~ health 
 14.31  care professional.  ~~The right of appeal must be communicated to~~ 
 14.32  ~~the enrollee or designee or to the attending physician, whomever~~ 
 14.33  ~~initiated the original certification request, at the time that~~ 
 14.34  ~~the original determination is communicated.~~ 
 14.35     Subd. 2.  [EXPEDITED APPEAL.] (a) When an initial 
 14.36  determination not to certify a health care service is made prior 
 15.1   to or during an ongoing service requiring review~~,~~ and the 
 15.2   attending ~~physician~~ health care professional believes that the 
 15.3   determination warrants ~~immediate~~ an expedited appeal, the 
 15.4   utilization review organization must ensure that the enrollee 
 15.5   and the attending ~~physician~~ health care professional, ~~enrollee,~~ 
 15.6   ~~or designee has~~ have an opportunity to appeal the determination 
 15.7   over the telephone on an expedited basis.  In such an appeal, 
 15.8   the utilization review organization must ensure reasonable 
 15.9   access to its consulting physician or health care 
 15.10  provider.  ~~Expedited appeals that are not resolved may be~~ 
 15.11  ~~resubmitted through the standard appeal process.~~ 
 15.12     (b) The utilization review organization shall notify the 
 15.13  enrollee and attending health care professional by telephone of 
 15.14  its determination on the expedited appeal as expeditiously as 
 15.15  the enrollee's medical condition requires, but no later than 72 
 15.16  hours after receiving the expedited appeal. 
 15.17     (c) If the determination not to certify is not reversed 
 15.18  through the expedited appeal, the utilization review 
 15.19  organization must include in its notification the right to 
 15.20  submit the appeal to the external appeal process described in 
 15.21  section 62Q.73 and the procedure for initiating the process.  
 15.22  This information must be provided in writing to the enrollee and 
 15.23  the attending health care professional within ten days. 
 15.24     Subd. 3.  [STANDARD APPEAL.] The utilization review 
 15.25  organization must establish procedures for appeals to be made 
 15.26  either in writing or by telephone. 
 15.27     (a) ~~Each~~ A utilization review organization shall notify in 
 15.28  writing the enrollee ~~or patient~~, attending ~~physician~~ health care 
 15.29  professional, and claims administrator of its determination on 
 15.30  the appeal ~~as soon as practical, but in no case later than 45~~ 
 15.31  ~~days after receiving the required documentation on the~~ 
 15.32  ~~appeal~~ within 30 days upon receipt of the notice of appeal.  
 15.33     (b) The documentation required by the utilization review 
 15.34  organization may include copies of part or all of the medical 
 15.35  record and a written statement from the attending health care 
 15.36  ~~provider~~ professional. 
 16.1      (c) Prior to upholding the ~~original decision~~ initial 
 16.2   determination not to certify for clinical reasons, the 
 16.3   utilization review organization shall conduct a review of the 
 16.4   documentation by a physician who did not make the ~~original~~ 
 16.5   initial determination not to certify. 
 16.6      (d) The process established by a utilization review 
 16.7   organization may include defining a period within which an 
 16.8   appeal must be filed to be considered.  The time period must be 
 16.9   communicated to the ~~patient,~~ enrollee~~, or~~ and attending 
 16.10  ~~physician~~ health care professional when the initial 
 16.11  determination is made. 
 16.12     (e) An attending ~~physician~~ health care professional or 
 16.13  enrollee who has been unsuccessful in an attempt to reverse a 
 16.14  determination not to certify shall, consistent with section 
 16.15  72A.285, be provided the following: 
 16.16     (1) a complete summary of the review findings; 
 16.17     (2) qualifications of the reviewers, including any license, 
 16.18  certification, or specialty designation; and 
 16.19     (3) the relationship between the enrollee's diagnosis and 
 16.20  the review criteria used as the basis for the decision, 
 16.21  including the specific rationale for the reviewer's decision. 
 16.22     (f) In cases of appeal to reverse a determination not to 
 16.23  certify for clinical reasons, the utilization review 
 16.24  organization must, upon request of the attending ~~physician~~ 
 16.25  health care professional, ensure that a physician of the 
 16.26  utilization review organization's choice in the same or a 
 16.27  similar general specialty as typically manages the medical 
 16.28  condition, procedure, or treatment under discussion is 
 16.29  reasonably available to review the case. 
 16.30     (g) If the initial determination is not reversed on appeal, 
 16.31  the utilization review organization must include in its 
 16.32  notification the right to submit the appeal to the external 
 16.33  appeal process described in section 62Q.73 and the procedure for 
 16.34  initiating the external process. 
 16.35     Subd. 3a.  [SECOND APPEAL OPTION.] (a) The utilization 
 16.36  review organization may establish an appeal process that offers 
 17.1   a second appeal if the determination not to certify is not 
 17.2   reversed through the standard appeal.  If the utilization review 
 17.3   organization offers a second appeal, the process must meet the 
 17.4   requirements of the internal appeal process described in section 
 17.5   62Q.70. 
 17.6      (b) If a utilization review organization offers a second 
 17.7   appeal, an enrollee is not required to exhaust the second appeal 
 17.8   process before submitting the determination not to certify to 
 17.9   the external appeal process pursuant to section 62Q.73. 
 17.10     Subd. 4.  [NOTIFICATION TO CLAIMS ADMINISTRATOR.] If the 
 17.11  utilization review organization and the claims administrator are 
 17.12  separate entities, the utilization review organization 
 17.13  must ~~forward~~ notify, either electronically or in writing, ~~a~~ 
 17.14  ~~notification of certification or determination not to certify to~~ 
 17.15  the appropriate claims administrator for the health benefit plan 
 17.16  of any determination not to certify that is reversed on appeal. 
 17.17     Sec. 24.  Minnesota Statutes 1998, section 62M.07, is 
 17.18  amended to read: 
 17.19     62M.07 [PRIOR AUTHORIZATION OF SERVICES.] 
 17.20     (a) Utilization review organizations conducting prior 
 17.21  authorization of services must have written standards that meet 
 17.22  at a minimum the following requirements: 
 17.23     (1) written procedures and criteria used to determine 
 17.24  whether care is appropriate, reasonable, or medically necessary; 
 17.25     (2) a system for providing prompt notification of its 
 17.26  determinations to enrollees and providers and for notifying the 
 17.27  provider, enrollee, or enrollee's designee of appeal procedures 
 17.28  under clause (4); 
 17.29     (3) compliance with section ~~72A.201~~ 62M.05, subdivision ~~4a~~ 
 17.30  3, regarding time frames for approving and disapproving prior 
 17.31  authorization requests; 
 17.32     (4) written procedures for appeals of denials of prior 
 17.33  authorization which specify the responsibilities of the enrollee 
 17.34  and provider, and which meet the requirements of ~~section~~ 
 17.35  sections 62M.06 and 72A.285, regarding release of summary review 
 17.36  findings; and 
 18.1      (5) procedures to ensure confidentiality of 
 18.2   patient-specific information, consistent with applicable law. 
 18.3      (b) No utilization review organization, health plan 
 18.4   company, or claims administrator may conduct or require prior 
 18.5   authorization of emergency confinement or emergency treatment.  
 18.6   The enrollee or the enrollee's authorized representative may be 
 18.7   required to notify the health plan company, claims 
 18.8   administrator, or utilization review organization as soon after 
 18.9   the beginning of the emergency confinement or emergency 
 18.10  treatment as reasonably possible. 
 18.11     Sec. 25.  Minnesota Statutes 1998, section 62M.09, 
 18.12  subdivision 3, is amended to read: 
 18.13     Subd. 3.  [PHYSICIAN REVIEWER INVOLVEMENT.] A physician 
 18.14  must review all cases in which the utilization review 
 18.15  organization has concluded that a determination not to certify 
 18.16  for clinical reasons is appropriate.  The physician should be 
 18.17  reasonably available by telephone to discuss the determination 
 18.18  with the attending ~~physician~~ health care professional.  This 
 18.19  subdivision does not apply to outpatient mental health or 
 18.20  substance abuse services governed by subdivision 3a.  
 18.21     Sec. 26.  Minnesota Statutes 1998, section 62M.10, 
 18.22  subdivision 2, is amended to read: 
 18.23     Subd. 2.  [REVIEWS DURING NORMAL BUSINESS HOURS.] A 
 18.24  utilization review organization must conduct its telephone 
 18.25  reviews, on-site reviews, and hospital communications during 
 18.26  ~~hospitals' and physicians'~~ reasonable and normal business hours, 
 18.27  unless otherwise mutually agreed. 
 18.28     Sec. 27.  Minnesota Statutes 1998, section 62M.10, 
 18.29  subdivision 5, is amended to read: 
 18.30     Subd. 5.  [ORAL REQUESTS FOR INFORMATION.] Utilization 
 18.31  review organizations shall orally inform, upon request, 
 18.32  designated hospital personnel or the attending ~~physician~~ health 
 18.33  care professional of the utilization review requirements of the 
 18.34  specific health benefit plan and the general type of criteria 
 18.35  used by the review agent.  Utilization review organizations 
 18.36  should also orally inform, upon request, ~~hospitals, physicians,~~ 
 19.1   ~~and other health care professionals~~ a provider of the 
 19.2   operational procedures in order to facilitate the review process.
 19.3      Sec. 28.  Minnesota Statutes 1998, section 62M.10, 
 19.4   subdivision 7, is amended to read: 
 19.5      Subd. 7.  [AVAILABILITY OF CRITERIA.] Upon request, a 
 19.6   utilization review organization shall provide to an enrollee or 
 19.7   to ~~an attending physician or~~ a provider the criteria used for a 
 19.8   specific procedure to determine the necessity, appropriateness, 
 19.9   and efficacy of that procedure and identify the database, 
 19.10  professional treatment guideline, or other basis for the 
 19.11  criteria. 
 19.12     Sec. 29.  Minnesota Statutes 1998, section 62M.12, is 
 19.13  amended to read: 
 19.14     62M.12 [PROHIBITION OF INAPPROPRIATE INCENTIVES.] 
 19.15     No individual who is performing utilization review may 
 19.16  receive any financial incentive based on the number of denials 
 19.17  of certifications made by such individual, provided that 
 19.18  utilization review organizations may establish medically 
 19.19  appropriate performance standards.  This prohibition does not 
 19.20  apply to financial incentives established between health ~~plans~~ 
 19.21  plan companies and ~~their~~ providers. 
 19.22     Sec. 30.  Minnesota Statutes 1998, section 62M.15, is 
 19.23  amended to read: 
 19.24     62M.15 [APPLICABILITY OF OTHER CHAPTER REQUIREMENTS.] 
 19.25     The requirements of this chapter regarding the conduct of 
 19.26  utilization review are in addition to any specific requirements 
 19.27  contained in chapter 62A, 62C, 62D, 62Q, or 72A. 
 19.28     Sec. 31.  Minnesota Statutes 1998, section 62Q.106, is 
 19.29  amended to read: 
 19.30     62Q.106 [DISPUTE RESOLUTION BY COMMISSIONER.] 
 19.31     A complainant may at any time submit a complaint to the 
 19.32  appropriate commissioner to investigate.  After investigating a 
 19.33  complaint, or reviewing a company's decision, the appropriate 
 19.34  commissioner may order a remedy as authorized under ~~section~~ 
 19.35  ~~62Q.30 or~~ chapter 45, 60A, or 62D.  
 19.36     Sec. 32.  Minnesota Statutes 1998, section 62Q.19, 
 20.1   subdivision 5a, is amended to read: 
 20.2      Subd. 5a.  [COOPERATION.] Each health plan company and 
 20.3   essential community provider shall cooperate to facilitate the 
 20.4   use of the essential community provider by the high risk and 
 20.5   special needs populations.  This includes cooperation on the 
 20.6   submission and processing of claims, sharing of all pertinent 
 20.7   records and data, including performance indicators and specific 
 20.8   outcomes data, and the use of all dispute resolution methods ~~as~~ 
 20.9   ~~defined in section 62Q.11, subdivision 1~~. 
 20.10     Sec. 33.  [62Q.68] [DEFINITIONS.] 
 20.11     Subdivision 1.  [APPLICATION.] For purposes of sections 
 20.12  62Q.68 to 62Q.72, the terms defined in this section have the 
 20.13  meanings given them. 
 20.14     Subd. 2.  [COMPLAINT.] "Complaint" means any grievance 
 20.15  against a health plan company that is not the subject of 
 20.16  litigation and that has been submitted by a complainant to a 
 20.17  health plan company regarding the provision of health services 
 20.18  including, but not limited to, the scope of coverage for health 
 20.19  care services; retrospective denials or limitations of payment 
 20.20  for services; eligibility issues; denials, cancellations, or 
 20.21  nonrenewals of coverage; administrative operations; and the 
 20.22  quality, timeliness, and appropriateness of health care services 
 20.23  rendered.  If the complaint is from an applicant, the complaint 
 20.24  must relate to the application.  If the complaint is from a 
 20.25  former enrollee, the complaint must relate to services received 
 20.26  during the period of time the individual was an enrollee.  Any 
 20.27  grievance requiring a medical determination in its resolution 
 20.28  must be processed under the appeal procedure described in 
 20.29  section 62M.06. 
 20.30     Subd. 3.  [COMPLAINANT.] "Complainant" means an enrollee, 
 20.31  applicant, or former enrollee, or anyone acting on behalf of an 
 20.32  enrollee, applicant, or former enrollee who submits a complaint. 
 20.33     Sec. 34.  [62Q.69] [COMPLAINT RESOLUTION.] 
 20.34     Subdivision 1.  [ESTABLISHMENT.] Each health plan company 
 20.35  must establish and maintain an internal complaint resolution 
 20.36  process that meets the requirements of this section to provide 
 21.1   for the resolution of a complaint initiated by a complainant. 
 21.2      Subd. 2.  [PROCEDURES FOR FILING A COMPLAINT.] (a) A 
 21.3   complainant may submit a complaint to a health plan company 
 21.4   either by telephone or in writing.  If a complaint is submitted 
 21.5   orally and the resolution of the complaint is partially or 
 21.6   wholly adverse to the complainant, or the oral complaint is not 
 21.7   resolved by the health plan company within ten days of receiving 
 21.8   the complaint, the health plan company must inform the 
 21.9   complainant that the complaint may be submitted in writing and 
 21.10  must promptly mail a complaint form to the complainant.  The 
 21.11  complaint form must include the following information: 
 21.12     (1) the telephone number of the office of health care 
 21.13  consumer assistance, advocacy, and information, and the health 
 21.14  plan company member services or other departments or persons 
 21.15  equipped to advise complainants on complaint resolution; 
 21.16     (2) the address to which the form must be sent; 
 21.17     (3) a description of the health plan company's internal 
 21.18  complaint procedure and the applicable time limits; and 
 21.19     (4) the toll-free telephone number of either the 
 21.20  commissioner of health or commerce and notification that the 
 21.21  complainant has the right to submit the complaint at any time to 
 21.22  the appropriate commissioner for investigation. 
 21.23     (b) Upon receipt of a written complaint, the health plan 
 21.24  company must notify the complainant within ten business days 
 21.25  that the complaint was received, unless the complaint is 
 21.26  resolved to the satisfaction of the complainant within the ten 
 21.27  business days. 
 21.28     (c) At the complainant's request, a health plan company 
 21.29  must provide a complainant with any assistance needed to file a 
 21.30  written complaint. 
 21.31     (d) Each health plan company must provide, in the member 
 21.32  handbook, subscriber contract, or certification of coverage, a 
 21.33  clear and concise description of how to submit a complaint and a 
 21.34  statement that, upon request, assistance in submitting a written 
 21.35  complaint is available from the health plan company. 
 21.36     Subd. 3.  [NOTIFICATION OF COMPLAINT DECISIONS.] (a) The 
 22.1   health plan company must notify the complainant in writing of 
 22.2   its decision and the reasons for it as soon as practical but in 
 22.3   no case later than 30 days after receipt of a written complaint. 
 22.4      (b) If the decision is partially or wholly adverse to the 
 22.5   complainant, the notification must inform the complainant of the 
 22.6   right to appeal the decision to either: 
 22.7      (1) the health plan company's internal appeal process 
 22.8   described in section 62Q.70 and the procedure for initiating an 
 22.9   appeal; or 
 22.10     (2) the external appeal process described in section 62Q.73 
 22.11  and the procedure for initiating the external process.  
 22.12     (c) The notification must also inform the complainant of 
 22.13  the right to submit the complaint at any time to either the 
 22.14  commissioner of health or commerce for investigation and the 
 22.15  toll-free telephone number of the appropriate commissioner. 
 22.16     Sec. 35.  [62Q.70] [APPEAL OF THE COMPLAINT DECISION.] 
 22.17     Subdivision 1.  [ESTABLISHMENT.] (a) Each health plan 
 22.18  company shall establish an internal appeal process for reviewing 
 22.19  a health plan company's decision regarding a complaint filed in 
 22.20  accordance with section 62Q.69.  The appeal process must meet 
 22.21  the requirements of this section.  
 22.22     (b) The person or persons with authority to resolve or 
 22.23  recommend the resolution of the internal appeal must not be 
 22.24  solely the same person or persons who made the complaint 
 22.25  decision under section 62Q.69. 
 22.26     (c) The internal appeal process must permit the receipt of 
 22.27  testimony, correspondence, explanations, or other information 
 22.28  from the complainant, staff persons, administrators, providers, 
 22.29  or other persons as deemed necessary by the person or persons 
 22.30  investigating or presiding over the appeal. 
 22.31     Subd. 2.  [PROCEDURES FOR FILING AN APPEAL.] If a 
 22.32  complainant notifies the health plan company of the 
 22.33  complainant's desire to appeal the health plan company's 
 22.34  decision regarding the complaint through the internal appeal 
 22.35  process, the health plan company must provide the complainant 
 22.36  the option for the appeal to occur either in writing or by 
 23.1   hearing. 
 23.2      Subd. 3.  [NOTIFICATION OF APPEAL DECISIONS.] (a) Written 
 23.3   notice of the appeal decision and all key findings must be given 
 23.4   to the complainant within 30 days of the health plan company's 
 23.5   receipt of the complainant's written notice of appeal. 
 23.6      (b) If the appeal decision is partially or wholly adverse 
 23.7   to the complainant, the notice must advise the complainant of 
 23.8   the right to submit the appeal decision to the external review 
 23.9   process described in section 62Q.73 and the procedure for 
 23.10  initiating the review process. 
 23.11     (c) Upon the request of the complainant, the health plan 
 23.12  company must provide the complainant with a complete summary of 
 23.13  the appeal decision.  
 23.14     Sec. 36.  [62Q.71] [NOTICE TO ENROLLEES.] 
 23.15     Each health plan company shall provide to enrollees a clear 
 23.16  and concise description of their complaint resolution procedure 
 23.17  and the procedure used for utilization review as defined under 
 23.18  chapter 62M as part of the member handbook, subscriber contract, 
 23.19  or certificate of coverage.  The description must specifically 
 23.20  inform enrollees:  
 23.21     (1) how to submit a complaint to the health plan company; 
 23.22     (2) if the health plan includes utilization review 
 23.23  requirements, how to notify the utilization review organization 
 23.24  in a timely manner and how to obtain certification for health 
 23.25  care services; 
 23.26     (3) how to request an appeal either through the procedures 
 23.27  described in sections 62Q.69 and 62Q.70 or through the 
 23.28  procedures described in chapter 62M; 
 23.29     (4) of the right to file a complaint with either the 
 23.30  commissioner of health or commerce at any time during the 
 23.31  complaint and appeal process; 
 23.32     (5) the toll-free telephone number of the appropriate 
 23.33  commissioner; 
 23.34     (6) the telephone number of the office of consumer 
 23.35  assistance, advocacy, and information; and 
 23.36     (7) of the right to obtain an external appeal under section 
 24.1   62Q.73 and a description of when and how that right may be 
 24.2   exercised. 
 24.3      Sec. 37.  [62Q.72] [RECORDKEEPING; REPORTING.] 
 24.4      Subdivision 1.  [RECORDKEEPING.] Each health plan company 
 24.5   shall maintain records of all enrollee complaints and their 
 24.6   resolutions.  These records shall be retained for five years and 
 24.7   shall be made available to the appropriate commissioner upon 
 24.8   request. 
 24.9      Subd. 2.  [REPORTING.] Each health plan company shall 
 24.10  submit to the appropriate commissioner, as part of the company's 
 24.11  annual filing, data on the number and type of complaints that 
 24.12  are not resolved within 30 days.  A health plan company shall 
 24.13  also make this information available to the public upon request. 
 24.14     Sec. 38.  [62Q.73] [EXTERNAL REVIEW OF ADVERSE 
 24.15  DETERMINATIONS.] 
 24.16     Subdivision 1.  [DEFINITIONS.] (a) For purposes of this 
 24.17  section, the term defined in this subdivision has the meaning 
 24.18  given it. 
 24.19     (b) An adverse determination means:  
 24.20     (1) a complaint decision relating to a health care service 
 24.21  or claim made in accordance with section 62Q.67 or an appeal 
 24.22  decision made in accordance with section 62Q.68 that is 
 24.23  partially or wholly adverse to the complainant; or 
 24.24     (2) any initial determination not to certify made in 
 24.25  accordance with section 62M.05 or an appeal made in accordance 
 24.26  with section 62M.06 that does not reverse an initial 
 24.27  determination not to certify. 
 24.28  An adverse determination does not include complaints relating to 
 24.29  fraudulent marketing practices or agent misrepresentation. 
 24.30     Subd. 2.  [RIGHT TO EXTERNAL REVIEW.] (a) Any enrollee or 
 24.31  anyone acting on behalf of an enrollee who has received an 
 24.32  adverse determination may submit a written request for an 
 24.33  external review of the adverse determination.  
 24.34     (b) If an enrollee requests an external review, the health 
 24.35  plan company must participate in the external review. 
 24.36     Subd. 3.  [CONTRACT.] Pursuant to a request for proposal, 
 25.1   the commissioner of administration, in consultation with the 
 25.2   commissioners of health and commerce, shall contract with an 
 25.3   organization or business entity to provide independent external 
 25.4   reviews of all adverse determinations submitted for external 
 25.5   review. 
 25.6      Subd. 4.  [CRITERIA.] The request for proposal must require 
 25.7   that the entity be affiliated with an institution of higher 
 25.8   learning and demonstrate: 
 25.9      (1) no conflicts of interest in that it is not owned, a 
 25.10  subsidiary of, or affiliated with a health plan company or 
 25.11  utilization review organization; 
 25.12     (2) an expertise in dispute resolution; 
 25.13     (3) an expertise in health related law; 
 25.14     (4) an ability to conduct reviews using a variety of 
 25.15  procedures depending upon the nature of the dispute; 
 25.16     (5) an ability to provide data to the commissioners of 
 25.17  health and commerce on the resolution of reviews; and 
 25.18     (6) an ability to ensure confidentiality of medical records 
 25.19  and other enrollee information. 
 25.20     Subd. 5.  [PROCESS.] (a) Upon receiving a request for an 
 25.21  external review, the external review entity must provide 
 25.22  immediate notice of the review to the enrollee and to the health 
 25.23  plan company.  Within ten business days of receiving notice of 
 25.24  the review, the health plan company and the enrollee must 
 25.25  provide the external review entity with any information that 
 25.26  they wish to be considered.  Each party shall be provided an 
 25.27  opportunity to present its version of the facts and arguments.  
 25.28  An enrollee may be assisted or represented by a person of the 
 25.29  enrollee's choice. 
 25.30     (b) As part of the external review process, an independent 
 25.31  medical opinion may be sought or a medical review panel may be 
 25.32  established to provide additional technical expertise. 
 25.33     (c) An external review shall be made as soon as practical 
 25.34  but in no case later than 40 days after receiving the request 
 25.35  for an external review and must promptly send written notice of 
 25.36  the decision and the reasons for it to the enrollee and the 
 26.1   health plan company. 
 26.2      Subd. 6.  [EFFECTS OF EXTERNAL REVIEW.] A decision rendered 
 26.3   under this section shall be nonbinding on the enrollee and 
 26.4   binding on the health plan company.  The health plan company may 
 26.5   seek judicial review of the decision on the grounds that the 
 26.6   decision was arbitrary and capricious or involved an abuse of 
 26.7   discretion. 
 26.8      Subd. 7.  [IMMUNITY FROM CIVIL LIABILITY.] A person who 
 26.9   participates in an external review by investigating, reviewing 
 26.10  materials, providing technical expertise, or rendering a 
 26.11  decision shall not be civilly liable for any action that is 
 26.12  taken in good faith, that is within the scope of the person's 
 26.13  duties, and that does not constitute willful or reckless 
 26.14  misconduct. 
 26.15     Subd. 8.  [ATTORNEY FEES.] The commissioner may award 
 26.16  attorney fees to the enrollee if the commissioner determines 
 26.17  such an award is warranted. 
 26.18     Subd. 9.  [DATA PRIVACY.] Any medical record provided for 
 26.19  the purpose of conducting an external review shall remain 
 26.20  confidential and shall be used only for the purpose of rendering 
 26.21  a decision under this section. 
 26.22     Subd. 10.  [DATA REPORTING.] (a) The entity conducting the 
 26.23  external review must provide the commissioner with the number of 
 26.24  reviews heard and a summary of each decision rendered, including 
 26.25  its disposition. 
 26.26     (b) The commissioners shall make available to the public, 
 26.27  upon request, summary data on the decisions rendered under this 
 26.28  section, including the number of reviews heard and decided and 
 26.29  the final outcomes. 
 26.30     Sec. 39.  Minnesota Statutes 1998, section 62T.04, is 
 26.31  amended to read: 
 26.32     62T.04 [COMPLAINT SYSTEM.] 
 26.33     Accountable provider networks must establish and maintain 
 26.34  an enrollee complaint system as required under ~~section~~ 
 26.35  ~~62Q.105~~ sections 62Q.68 to 62Q.72.  The accountable provider 
 26.36  network may contract with the health care purchasing alliance or 
 27.1   a vendor for operation of this system. 
 27.2      Sec. 40.  Minnesota Statutes 1998, section 72A.201, 
 27.3   subdivision 4, is amended to read: 
 27.4      Subd. 4.  [STANDARDS FOR CLAIM FILING AND HANDLING.] The 
 27.5   following acts by an insurer, an adjuster, a self-insured, or a 
 27.6   self-insurance administrator constitute unfair settlement 
 27.7   practices:  
 27.8      (1) except for claims made under a health insurance policy, 
 27.9   after receiving notification of claim from an insured or a 
 27.10  claimant, failing to acknowledge receipt of the notification of 
 27.11  the claim within ten business days, and failing to promptly 
 27.12  provide all necessary claim forms and instructions to process 
 27.13  the claim, unless the claim is settled within ten business 
 27.14  days.  The acknowledgment must include the telephone number of 
 27.15  the company representative who can assist the insured or the 
 27.16  claimant in providing information and assistance that is 
 27.17  reasonable so that the insured or claimant can comply with the 
 27.18  policy conditions and the insurer's reasonable requirements.  If 
 27.19  an acknowledgment is made by means other than writing, an 
 27.20  appropriate notation of the acknowledgment must be made in the 
 27.21  claim file of the insurer and dated.  An appropriate notation 
 27.22  must include at least the following information where the 
 27.23  acknowledgment is by telephone or oral contact:  
 27.24     (i) the telephone number called, if any; 
 27.25     (ii) the name of the person making the telephone call or 
 27.26  oral contact; 
 27.27     (iii) the name of the person who actually received the 
 27.28  telephone call or oral contact; 
 27.29     (iv) the time of the telephone call or oral contact; and 
 27.30     (v) the date of the telephone call or oral contact; 
 27.31     (2) failing to reply, within ten business days of receipt, 
 27.32  to all other communications about a claim from an insured or a 
 27.33  claimant that reasonably indicate a response is requested or 
 27.34  needed; 
 27.35     (3) unless provided otherwise by law or in the policy, 
 27.36  failing to complete its investigation and inform the insured or 
 28.1   claimant of acceptance or denial of a claim within 30 business 
 28.2   days after receipt of notification of claim unless the 
 28.3   investigation cannot be reasonably completed within that time. 
 28.4   In the event that the investigation cannot reasonably be 
 28.5   completed within that time, the insurer shall notify the insured 
 28.6   or claimant within the time period of the reasons why the 
 28.7   investigation is not complete and the expected date the 
 28.8   investigation will be complete.  ~~For~~ Claims made under a health 
 28.9   policy ~~the notification of claim must be in writing~~ must be 
 28.10  processed in accordance with sections 62Q.68 to 62Q.73; 
 28.11     (4) where evidence of suspected fraud is present, the 
 28.12  requirement to disclose their reasons for failure to complete 
 28.13  the investigation within the time period set forth in clause (3) 
 28.14  need not be specific.  The insurer must make this evidence 
 28.15  available to the department of commerce if requested; 
 28.16     (5) failing to notify an insured who has made a 
 28.17  notification of claim of all available benefits or coverages 
 28.18  which the insured may be eligible to receive under the terms of 
 28.19  a policy and of the documentation which the insured must supply 
 28.20  in order to ascertain eligibility; 
 28.21     (6) unless otherwise provided by law or in the policy, 
 28.22  requiring an insured to give written notice of loss or proof of 
 28.23  loss within a specified time, and thereafter seeking to relieve 
 28.24  the insurer of its obligations if the time limit is not complied 
 28.25  with, unless the failure to comply with the time limit 
 28.26  prejudices the insurer's rights and then only if the insurer 
 28.27  gave prior notice to the insured of the potential prejudice; 
 28.28     (7) advising an insured or a claimant not to obtain the 
 28.29  services of an attorney or an adjuster, or representing that 
 28.30  payment will be delayed if an attorney or an adjuster is 
 28.31  retained by the insured or the claimant; 
 28.32     (8) failing to advise in writing an insured or claimant who 
 28.33  has filed a notification of claim known to be unresolved, and 
 28.34  who has not retained an attorney, of the expiration of a statute 
 28.35  of limitations at least 60 days prior to that expiration.  For 
 28.36  the purposes of this clause, any claim on which the insurer has 
 29.1   received no communication from the insured or claimant for a 
 29.2   period of two years preceding the expiration of the applicable 
 29.3   statute of limitations shall not be considered to be known to be 
 29.4   unresolved and notice need not be sent pursuant to this clause; 
 29.5      (9) demanding information which would not affect the 
 29.6   settlement of the claim; 
 29.7      (10) unless expressly permitted by law or the policy, 
 29.8   refusing to settle a claim of an insured on the basis that the 
 29.9   responsibility should be assumed by others; 
 29.10     (11) failing, within 60 business days after receipt of a 
 29.11  properly executed proof of loss, to advise the insured of the 
 29.12  acceptance or denial of the claim by the insurer.  No insurer 
 29.13  shall deny a claim on the grounds of a specific policy 
 29.14  provision, condition, or exclusion unless reference to the 
 29.15  provision, condition, or exclusion is included in the denial. 
 29.16  The denial must be given to the insured in writing with a copy 
 29.17  filed in the claim file; 
 29.18     (12) denying or reducing a claim on the basis of an 
 29.19  application which was altered or falsified by the agent or 
 29.20  insurer without the knowledge of the insured; 
 29.21     (13) failing to notify the insured of the existence of the 
 29.22  additional living expense coverage when an insured under a 
 29.23  homeowners policy sustains a loss by reason of a covered 
 29.24  occurrence and the damage to the dwelling is such that it is not 
 29.25  habitable; 
 29.26     (14) failing to inform an insured or a claimant that the 
 29.27  insurer will pay for an estimate of repair if the insurer 
 29.28  requested the estimate and the insured or claimant had 
 29.29  previously submitted two estimates of repair.  
 29.30     Sec. 41.  Minnesota Statutes 1998, section 72A.201, 
 29.31  subdivision 4a, is amended to read: 
 29.32     Subd. 4a.  [STANDARDS FOR PREAUTHORIZATION APPROVAL.] If a 
 29.33  policy of accident and sickness insurance or a subscriber 
 29.34  contract requires preauthorization approval for any nonemergency 
 29.35  services or benefits, the decision to approve or disapprove the 
 29.36  requested services or benefits must be ~~communicated to the~~ 
 30.1   ~~insured or the insured's health care provider within ten~~ 
 30.2   ~~business days of the preauthorization request provided that all~~ 
 30.3   ~~information reasonably necessary to make a decision on the~~ 
 30.4   ~~request has been made available to the insurer~~ processed in 
 30.5   accordance with section 62M.07. 
 30.6      Sec. 42.  Minnesota Statutes 1998, section 256B.692, 
 30.7   subdivision 2, is amended to read: 
 30.8      Subd. 2.  [DUTIES OF THE COMMISSIONER OF HEALTH.] 
 30.9   Notwithstanding chapters 62D and 62N, a county that elects to 
 30.10  purchase medical assistance and general assistance medical care 
 30.11  in return for a fixed sum without regard to the frequency or 
 30.12  extent of services furnished to any particular enrollee is not 
 30.13  required to obtain a certificate of authority under chapter 62D 
 30.14  or 62N.  A county that elects to purchase medical assistance and 
 30.15  general assistance medical care services under this section must 
 30.16  satisfy the commissioner of health that the requirements of 
 30.17  chapter 62D, applicable to health maintenance organizations, or 
 30.18  chapter 62N, applicable to community integrated service 
 30.19  networks, will be met.  A county must also assure the 
 30.20  commissioner of health that the requirements of sections 
 30.21  62J.041; 62J.48; 62J.71 to 62J.73; 62M.01 to 62M.16; all 
 30.22  applicable provisions of chapter 62Q, including sections 62Q.07; 
 30.23  62Q.075; ~~62Q.105;~~ 62Q.1055; 62Q.106; ~~62Q.11;~~ 62Q.12; 62Q.135; 
 30.24  62Q.14; 62Q.145; 62Q.19; 62Q.23, paragraph (c); ~~62Q.30;~~ 62Q.43; 
 30.25  62Q.47; 62Q.50; 62Q.52 to 62Q.56; 62Q.58; 62Q.64; 62Q.68 to 
 30.26  62Q.72; and 72A.201 will be met.  All enforcement and rulemaking 
 30.27  powers available under chapters 62D, 62J, 62M, 62N, and 62Q are 
 30.28  hereby granted to the commissioner of health with respect to 
 30.29  counties that purchase medical assistance and general assistance 
 30.30  medical care services under this section. 
 30.31     Sec. 43.  [REPEALER.] 
 30.32     Minnesota Statutes 1998, sections 62D.11, subdivisions 1b 
 30.33  and 2; 62Q.105; 62Q.11; and 62Q.30, are repealed. 
 30.34     Minnesota Rules, parts 4685.0100, subparts 4 and 4a; and 
 30.35  4685.1700, are repealed.