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 review 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, subdivision 4a; and 256B.692, 
  1.13            subdivision 2; proposing coding for new law in 
  1.14            Minnesota Statutes, chapters 62D; and 62Q; repealing 
  1.15            Minnesota Statutes 1998, sections 62D.11, subdivisions 
  1.16            1b and 2; 62Q.105; and 62Q.30; Minnesota Rules, parts 
  1.17            4685.0100, subparts 4 and 4a; 4685.1010, subpart 3; 
  1.18            and 4685.1700. 
  1.19  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.20     Section 1.  Minnesota Statutes 1998, section 62D.11, 
  1.21  subdivision 1, is amended to read: 
  1.22     Subdivision 1.  [ENROLLEE COMPLAINT SYSTEM.] Every health 
  1.23  maintenance organization shall establish and maintain a 
  1.24  complaint system, as required under ~~section 62Q.105~~ sections 
  1.25  62Q.68 to 62Q.72 to provide reasonable procedures for the 
  1.26  resolution of written complaints initiated by or on behalf of 
  1.27  enrollees concerning the provision of health care 
  1.28  services.  ~~"Provision of health services" includes, but is not~~ 
  1.29  ~~limited to, questions of the scope of coverage, quality of care,~~ 
  1.30  ~~and administrative operations.  The health maintenance~~ 
  1.31  ~~organization must inform enrollees that they may choose to use~~ 
  1.32  ~~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.  [62D.124] [GEOGRAPHIC ACCESSIBILITY.] 
  2.9      Subdivision 1.  [PRIMARY CARE; MENTAL HEALTH SERVICES; 
  2.10  GENERAL HOSPITAL SERVICES.] Within the health maintenance 
  2.11  organization's service area, the maximum travel distance or time 
  2.12  shall be the lesser of 30 miles or 30 minutes to the nearest 
  2.13  provider of each of the following services:  primary care 
  2.14  services, mental health services, and general hospital 
  2.15  services.  The health maintenance organization must designate 
  2.16  which method is used.  
  2.17     Subd. 2.  [OTHER HEALTH SERVICES.] Within a health 
  2.18  maintenance organization's service area, the maximum travel 
  2.19  distance or time shall be the lesser of 60 miles or 60 minutes 
  2.20  to the nearest provider of specialty physician services, 
  2.21  ancillary services, specialized hospital services, and all other 
  2.22  health services not listed in subdivision 1.  The health 
  2.23  maintenance organization must designate which method is used. 
  2.24     Subd. 3.  [EXCEPTION.] The commissioner shall grant an 
  2.25  exception to the requirements of this section according to 
  2.26  Minnesota Rules, part 4685.1010, subpart 4, if the health 
  2.27  maintenance organization can demonstrate with specific data that 
  2.28  the requirement of subdivision 1 or 2 is not feasible in a 
  2.29  particular service area or part of a service area. 
  2.30     Subd. 4.  [APPLICATION.] (a) Subdivisions 1 and 2 do not 
  2.31  apply if an enrollee is referred to a referral center for health 
  2.32  care services.  
  2.33     (b) Subdivision 1 does not apply: 
  2.34     (1) if an enrollee has chosen a health plan with full 
  2.35  knowledge that the health plan has no participating providers 
  2.36  within 30 miles or 30 minutes of the enrollee's place of 
  3.1   residence; or 
  3.2      (2) to service areas approved before May 24, 1993. 
  3.3      Sec. 3.  Minnesota Statutes 1998, section 62M.01, is 
  3.4   amended to read: 
  3.5      62M.01 [CITATION, JURISDICTION, AND SCOPE.] 
  3.6      Subdivision 1.  [POPULAR NAME.] Sections 62M.01 to 62M.16 
  3.7   may be cited as the "Minnesota Utilization Review Act of 1992." 
  3.8      Subd. 2.  [JURISDICTION.] Sections 62M.01 to 62M.16 apply 
  3.9   to any insurance company licensed under chapter 60A to offer, 
  3.10  sell, or issue a policy of accident and sickness insurance as 
  3.11  defined in section 62A.01; a health service plan licensed under 
  3.12  chapter 62C; a health maintenance organization licensed under 
  3.13  chapter 62D; a community integrated service network licensed 
  3.14  under chapter 62N; an accountable provider network operating 
  3.15  under chapter 62T; a fraternal benefit society operating under 
  3.16  chapter 64B; a joint self-insurance employee health plan 
  3.17  operating under chapter 62H; a multiple employer welfare 
  3.18  arrangement, as defined in section 3 of the Employee Retirement 
  3.19  Income Security Act of 1974 (ERISA), United States Code, title 
  3.20  29, section 1103, as amended; a third party administrator 
  3.21  licensed under section 60A.23, subdivision 8, that provides 
  3.22  utilization review services for the administration of benefits 
  3.23  under a health benefit plan as defined in section 62M.02; or any 
  3.24  entity performing utilization review on behalf of a business 
  3.25  entity in this state pursuant to a health benefit plan covering 
  3.26  a Minnesota resident. 
  3.27     Subd. 3.  [SCOPE.] ~~Sections 62M.02, 62M.07, and 62M.09,~~ 
  3.28  ~~subdivision 4, apply to prior authorization of services.~~  
  3.29  Nothing in sections 62M.01 to 62M.16 applies to review of claims 
  3.30  after submission to determine eligibility for benefits under a 
  3.31  health benefit plan.  The appeal procedure described in section 
  3.32  62M.06 applies to any complaint as defined under section 62Q.68, 
  3.33  subdivision 2, that requires a medical determination in its 
  3.34  resolution.  
  3.35     Sec. 4.  Minnesota Statutes 1998, section 62M.02, 
  3.36  subdivision 3, is amended to read: 
  4.1      Subd. 3.  [ATTENDING DENTIST.] "Attending dentist" means 
  4.2   the dentist with primary responsibility for the dental care 
  4.3   provided to ~~a patient~~ an enrollee. 
  4.4      Sec. 5.  Minnesota Statutes 1998, section 62M.02, 
  4.5   subdivision 4, is amended to read: 
  4.6      Subd. 4.  [ATTENDING ~~PHYSICIAN~~ HEALTH CARE PROFESSIONAL.] 
  4.7   "Attending ~~physician~~ health care professional" means 
  4.8   the ~~physician~~ health care professional with primary 
  4.9   responsibility for the care provided to ~~a patient in a hospital~~ 
  4.10  ~~or other health care facility~~ an enrollee. 
  4.11     Sec. 6.  Minnesota Statutes 1998, section 62M.02, 
  4.12  subdivision 5, is amended to read: 
  4.13     Subd. 5.  [CERTIFICATION.] "Certification" means a 
  4.14  determination by a utilization review organization that an 
  4.15  admission, extension of stay, or other health care service has 
  4.16  been reviewed and that it, based on the information provided, 
  4.17  meets the utilization review requirements of the applicable 
  4.18  health plan and the health ~~carrier~~ plan company will then pay 
  4.19  for the covered benefit, provided the preexisting limitation 
  4.20  provisions, the general exclusion provisions, and any 
  4.21  deductible, copayment, coinsurance, or other policy requirements 
  4.22  have been met. 
  4.23     Sec. 7.  Minnesota Statutes 1998, section 62M.02, 
  4.24  subdivision 6, is amended to read: 
  4.25     Subd. 6.  [CLAIMS ADMINISTRATOR.] "Claims administrator" 
  4.26  means an entity that reviews and determines whether to pay 
  4.27  claims to enrollees~~, physicians, hospitals, or others~~ or 
  4.28  providers based on the contract provisions of the health plan 
  4.29  contract.  Claims administrators may include insurance companies 
  4.30  licensed under chapter 60A to offer, sell, or issue a policy of 
  4.31  accident and sickness insurance as defined in section 62A.01; a 
  4.32  health service plan licensed under chapter 62C; a health 
  4.33  maintenance organization licensed under chapter 62D; a community 
  4.34  integrated service network licensed under chapter 62N; an 
  4.35  accountable provider network operating under chapter 62T; a 
  4.36  fraternal benefit society operating under chapter 64B; a 
  5.1   multiple employer welfare arrangement, as defined in section 3 
  5.2   of the Employee Retirement Income Security Act of 1974 (ERISA), 
  5.3   United States Code, title 29, section 1103, as amended. 
  5.4      Sec. 8.  Minnesota Statutes 1998, section 62M.02, 
  5.5   subdivision 7, is amended to read: 
  5.6      Subd. 7.  [CLAIMANT.] "Claimant" means the enrollee ~~or~~ 
  5.7   ~~covered person~~ who files a claim for benefits or a provider of 
  5.8   services who, pursuant to a contract with a claims 
  5.9   administrator, files a claim on behalf of an enrollee or covered 
  5.10  person. 
  5.11     Sec. 9.  Minnesota Statutes 1998, section 62M.02, 
  5.12  subdivision 9, is amended to read: 
  5.13     Subd. 9.  [CONCURRENT REVIEW.] "Concurrent review" means 
  5.14  utilization review conducted during ~~a patient's~~ an enrollee's 
  5.15  hospital stay or course of treatment and has the same meaning as 
  5.16  continued stay review. 
  5.17     Sec. 10.  Minnesota Statutes 1998, section 62M.02, 
  5.18  subdivision 10, is amended to read: 
  5.19     Subd. 10.  [DISCHARGE PLANNING.] "Discharge planning" means 
  5.20  the process that assesses ~~a patient's~~ an enrollee's need for 
  5.21  treatment after hospitalization in order to help arrange for the 
  5.22  necessary services and resources to effect an appropriate and 
  5.23  timely discharge. 
  5.24     Sec. 11.  Minnesota Statutes 1998, section 62M.02, 
  5.25  subdivision 11, is amended to read: 
  5.26     Subd. 11.  [ENROLLEE.] "Enrollee" means an individual ~~who~~ 
  5.27  ~~has elected to contract for, or participate in, a health benefit~~ 
  5.28  ~~plan for enrollee coverage or for dependent coverage~~ covered by 
  5.29  a health benefit plan and includes an insured policyholder, 
  5.30  subscriber contract holder, member, covered person, or 
  5.31  certificate holder. 
  5.32     Sec. 12.  Minnesota Statutes 1998, section 62M.02, 
  5.33  subdivision 12, is amended to read: 
  5.34     Subd. 12.  [HEALTH BENEFIT PLAN.] "Health benefit plan" 
  5.35  means a policy, contract, or certificate issued by a health 
  5.36  ~~carrier to an employer or individual~~ plan company for the 
  6.1   coverage of medical, dental, or hospital benefits.  A health 
  6.2   benefit plan does not include coverage that is: 
  6.3      (1) limited to disability or income protection coverage; 
  6.4      (2) automobile medical payment coverage; 
  6.5      (3) supplemental to liability insurance; 
  6.6      (4) designed solely to provide payments on a per diem, 
  6.7   fixed indemnity, or nonexpense incurred basis; 
  6.8      (5) credit accident and health insurance issued under 
  6.9   chapter 62B; 
  6.10     (6) blanket accident and sickness insurance as defined in 
  6.11  section 62A.11; 
  6.12     (7) accident only coverage issued by a licensed and tested 
  6.13  insurance agent; or 
  6.14     (8) workers' compensation. 
  6.15     Sec. 13.  Minnesota Statutes 1998, section 62M.02, is 
  6.16  amended by adding a subdivision to read: 
  6.17     Subd. 12a.  [HEALTH PLAN COMPANY.] "Health plan company" 
  6.18  means a health plan company as defined in section 62Q.01, 
  6.19  subdivision 4, and includes an accountable provider network 
  6.20  operating under chapter 62T. 
  6.21     Sec. 14.  Minnesota Statutes 1998, section 62M.02, 
  6.22  subdivision 17, is amended to read: 
  6.23     Subd. 17.  [PROVIDER.] "Provider" means a licensed health 
  6.24  care facility, physician, or other health care professional that 
  6.25  delivers health care services to an enrollee ~~or covered person~~. 
  6.26     Sec. 15. Minnesota Statutes 1998, section 62M.02, 
  6.27  subdivision 20, is amended to read: 
  6.28     Subd. 20.  [UTILIZATION REVIEW.] "Utilization review" means 
  6.29  the evaluation of the necessity, appropriateness, and efficacy 
  6.30  of the use of health care services, procedures, and facilities, 
  6.31  by a person or entity other than the attending ~~physician~~ health 
  6.32  care professional, for the purpose of determining the medical 
  6.33  necessity of the service or admission.  Utilization review also 
  6.34  includes review conducted after the admission of the enrollee.  
  6.35  It includes situations where the enrollee is unconscious or 
  6.36  otherwise unable to provide advance notification.  ~~Utilization~~ 
  7.1   ~~review does not include the imposition of a requirement that~~ 
  7.2   ~~services be received by or upon referral from a participating~~ 
  7.3   ~~provider.~~ 
  7.4      Sec. 16.  Minnesota Statutes 1998, section 62M.02, 
  7.5   subdivision 21, is amended to read: 
  7.6      Subd. 21.  [UTILIZATION REVIEW ORGANIZATION.] "Utilization 
  7.7   review organization" means an entity including but not limited 
  7.8   to an insurance company licensed under chapter 60A to offer, 
  7.9   sell, or issue a policy of accident and sickness insurance as 
  7.10  defined in section 62A.01; a health service plan licensed under 
  7.11  chapter 62C; a health maintenance organization licensed under 
  7.12  chapter 62D; a community integrated service network licensed 
  7.13  under chapter 62N; an accountable provider network operating 
  7.14  under chapter 62T; a fraternal benefit society operating under 
  7.15  chapter 64B; a joint self-insurance employee health plan 
  7.16  operating under chapter 62H; a multiple employer welfare 
  7.17  arrangement, as defined in section 3 of the Employee Retirement 
  7.18  Income Security Act of 1974 (ERISA), United States Code, title 
  7.19  29, section 1103, as amended; a third party administrator 
  7.20  licensed under section 60A.23, subdivision 8, which conducts 
  7.21  utilization review and determines certification of an admission, 
  7.22  extension of stay, or other health care services for a Minnesota 
  7.23  resident; or any entity performing utilization review that is 
  7.24  affiliated with, under contract with, or conducting utilization 
  7.25  review on behalf of, a business entity in this state. 
  7.26     Sec. 17.  Minnesota Statutes 1998, section 62M.03, 
  7.27  subdivision 1, is amended to read: 
  7.28     Subdivision 1.  [LICENSED UTILIZATION REVIEW ORGANIZATION.] 
  7.29  Beginning January 1, 1993, any organization that meets the 
  7.30  definition of utilization review organization in section 62M.02, 
  7.31  subdivision 21, must be licensed under chapter 60A, 62C, 62D, 
  7.32  62N, 62T, or 64B, or registered under this chapter and must 
  7.33  comply with sections 62M.01 to 62M.16 and section 72A.201, 
  7.34  subdivisions 8 and 8a.  Each licensed community integrated 
  7.35  service network or health maintenance organization that has an 
  7.36  employed staff model of providing health care services shall 
  8.1   comply with sections 62M.01 to 62M.16 and section 72A.201, 
  8.2   subdivisions 8 and 8a, for any services provided by providers 
  8.3   under contract. 
  8.4      Sec. 18.  Minnesota Statutes 1998, section 62M.03, 
  8.5   subdivision 3, is amended to read: 
  8.6      Subd. 3.  [PENALTIES AND ENFORCEMENTS.] If a utilization 
  8.7   review organization fails to comply with sections 62M.01 to 
  8.8   62M.16, the organization may not provide utilization review 
  8.9   services for any Minnesota resident.  The commissioner of 
  8.10  commerce may issue a cease and desist order under section 
  8.11  45.027, subdivision 5, to enforce this provision.  The cease and 
  8.12  desist order is subject to appeal under chapter 14.  A 
  8.13  nonlicensed utilization review organization that fails to comply 
  8.14  with the provisions of sections 62M.01 to 62M.16 is subject to 
  8.15  all applicable penalty and enforcement provisions of section 
  8.16  72A.201.  Each utilization review organization licensed under 
  8.17  chapter 60A, 62C, 62D, 62N, 62T, or 64B shall comply with 
  8.18  sections 62M.01 to 62M.16 as a condition of licensure. 
  8.19     Sec. 19.  Minnesota Statutes 1998, section 62M.04, 
  8.20  subdivision 1, is amended to read: 
  8.21     Subdivision 1.  [RESPONSIBILITY FOR OBTAINING 
  8.22  CERTIFICATION.] A health benefit plan that includes utilization 
  8.23  review requirements must specify the process for notifying the 
  8.24  utilization review organization in a timely manner and obtaining 
  8.25  certification for health care services.  Each health plan 
  8.26  company must provide a clear and concise description of this 
  8.27  process to an enrollee as part of the policy, subscriber 
  8.28  contract, or certificate of coverage.  In addition to the 
  8.29  enrollee, the utilization review organization must allow any 
  8.30  ~~licensed hospital, physician or the physician's~~ provider or 
  8.31  provider's designee, or responsible patient representative, 
  8.32  including a family member, to fulfill the obligations under the 
  8.33  health plan. 
  8.34     A claims administrator that contracts directly with 
  8.35  providers for the provision of health care services to enrollees 
  8.36  may, through contract, require the provider to notify the review 
  9.1   organization in a timely manner and obtain certification for 
  9.2   health care services. 
  9.3      Sec. 20.  Minnesota Statutes 1998, section 62M.04, 
  9.4   subdivision 2, is amended to read: 
  9.5      Subd. 2.  [INFORMATION UPON WHICH UTILIZATION REVIEW IS 
  9.6   CONDUCTED.] If the utilization review organization is conducting 
  9.7   routine prospective and concurrent utilization review, 
  9.8   utilization review organizations must collect only the 
  9.9   information necessary to certify the admission, procedure of 
  9.10  treatment, and length of stay. 
  9.11     (a) Utilization review organizations may request, but may 
  9.12  not require~~, hospitals, physicians, or other~~ providers to supply 
  9.13  numerically encoded diagnoses or procedures as part of the 
  9.14  certification process. 
  9.15     (b) Utilization review organizations must not routinely 
  9.16  request copies of medical records for all patients reviewed.  In 
  9.17  performing prospective and concurrent review, copies of the 
  9.18  pertinent portion of the medical record should be required only 
  9.19  when a difficulty develops in certifying the medical necessity 
  9.20  or appropriateness of the admission or extension of stay. 
  9.21     (c) Utilization review organizations may request copies of 
  9.22  medical records retrospectively for a number of purposes, 
  9.23  including auditing the services provided, quality assurance 
  9.24  review, ensuring compliance with the terms of either the health 
  9.25  benefit plan or the provider contract, and compliance with 
  9.26  utilization review activities.  Except for reviewing medical 
  9.27  records associated with an appeal or with an investigation or 
  9.28  audit of data discrepancies, ~~health care~~ providers must be 
  9.29  reimbursed for the reasonable costs of duplicating records 
  9.30  requested by the utilization review organization for 
  9.31  retrospective review unless otherwise provided under the terms 
  9.32  of the provider contract. 
  9.33     Sec. 21.  Minnesota Statutes 1998, section 62M.04, 
  9.34  subdivision 3, is amended to read: 
  9.35     Subd. 3.  [DATA ELEMENTS.] Except as otherwise provided in 
  9.36  sections 62M.01 to 62M.16, for purposes of certification a 
 10.1   utilization review organization must limit its data requirements 
 10.2   to the following elements: 
 10.3      (a) Patient information that includes the following: 
 10.4      (1) name; 
 10.5      (2) address; 
 10.6      (3) date of birth; 
 10.7      (4) sex; 
 10.8      (5) social security number or patient identification 
 10.9   number; 
 10.10     (6) name of health ~~carrier~~ plan company or health plan; and 
 10.11     (7) plan identification number. 
 10.12     (b) Enrollee information that includes the following: 
 10.13     (1) name; 
 10.14     (2) address; 
 10.15     (3) social security number or employee identification 
 10.16  number; 
 10.17     (4) relation to patient; 
 10.18     (5) employer; 
 10.19     (6) health benefit plan; 
 10.20     (7) group number or plan identification number; and 
 10.21     (8) availability of other coverage. 
 10.22     (c) Attending ~~physician or provider~~ health care 
 10.23  professional information that includes the following: 
 10.24     (1) name; 
 10.25     (2) address; 
 10.26     (3) telephone numbers; 
 10.27     (4) degree and license; 
 10.28     (5) specialty or board certification status; and 
 10.29     (6) tax identification number or other identification 
 10.30  number. 
 10.31     (d) Diagnosis and treatment information that includes the 
 10.32  following: 
 10.33     (1) primary diagnosis with associated ICD or DSM coding, if 
 10.34  available; 
 10.35     (2) secondary diagnosis with associated ICD or DSM coding, 
 10.36  if available; 
 11.1      (3) tertiary diagnoses with associated ICD or DSM coding, 
 11.2   if available; 
 11.3      (4) proposed procedures or treatments with ICD or 
 11.4   associated CPT codes, if available; 
 11.5      (5) surgical assistant requirement; 
 11.6      (6) anesthesia requirement; 
 11.7      (7) proposed admission or service dates; 
 11.8      (8) proposed procedure date; and 
 11.9      (9) proposed length of stay. 
 11.10     (e) Clinical information that includes the following: 
 11.11     (1) support and documentation of appropriateness and level 
 11.12  of service proposed; and 
 11.13     (2) identification of contact person for detailed clinical 
 11.14  information. 
 11.15     (f) Facility information that includes the following:  
 11.16     (1) type; 
 11.17     (2) licensure and certification status and DRG exempt 
 11.18  status; 
 11.19     (3) name; 
 11.20     (4) address; 
 11.21     (5) telephone number; and 
 11.22     (6) tax identification number or other identification 
 11.23  number. 
 11.24     (g) Concurrent or continued stay review information that 
 11.25  includes the following: 
 11.26     (1) additional days, services, or procedures proposed; 
 11.27     (2) reasons for extension, including clinical information 
 11.28  sufficient for support of appropriateness and level of service 
 11.29  proposed; and 
 11.30     (3) diagnosis status. 
 11.31     (h) For admissions to facilities other than acute medical 
 11.32  or surgical hospitals, additional information that includes the 
 11.33  following: 
 11.34     (1) history of present illness; 
 11.35     (2) patient treatment plan and goals; 
 11.36     (3) prognosis; 
 12.1      (4) staff qualifications; and 
 12.2      (5) 24-hour availability of staff. 
 12.3      Additional information may be required for other specific 
 12.4   review functions such as discharge planning or catastrophic case 
 12.5   management.  Second opinion information may also be required, 
 12.6   when applicable, to support benefit plan requirements. 
 12.7      Sec. 22.  Minnesota Statutes 1998, section 62M.04, 
 12.8   subdivision 4, is amended to read: 
 12.9      Subd. 4.  [ADDITIONAL INFORMATION.] A utilization review 
 12.10  organization may request information in addition to that 
 12.11  described in subdivision 3 when there is significant lack of 
 12.12  agreement between the utilization review organization and the 
 12.13  ~~health care~~ provider regarding the appropriateness of 
 12.14  certification during the review or appeal process.  For purposes 
 12.15  of this subdivision, "significant lack of agreement" means that 
 12.16  the utilization review organization has: 
 12.17     (1) tentatively determined through its professional staff 
 12.18  that a service cannot be certified; 
 12.19     (2) referred the case to a physician for review; and 
 12.20     (3) talked to or attempted to talk to the attending 
 12.21  ~~physician~~ health care professional for further information. 
 12.22     Nothing in sections 62M.01 to 62M.16 prohibits a 
 12.23  utilization review organization from requiring submission of 
 12.24  data necessary to comply with the quality assurance and 
 12.25  utilization review requirements of chapter 62D or other 
 12.26  appropriate data or outcome analyses. 
 12.27     Sec. 23.  Minnesota Statutes 1998, section 62M.05, is 
 12.28  amended to read: 
 12.29     62M.05 [PROCEDURES FOR REVIEW DETERMINATION.] 
 12.30     Subdivision 1.  [WRITTEN PROCEDURES.] A utilization review 
 12.31  organization must have written procedures to ensure that reviews 
 12.32  are conducted in accordance with the requirements of this 
 12.33  chapter ~~and section 72A.201, subdivision 4a~~. 
 12.34     Subd. 2.  [CONCURRENT REVIEW.] A utilization review 
 12.35  organization may review ongoing inpatient stays based on the 
 12.36  severity or complexity of the ~~patient's~~ enrollee's condition or 
 13.1   on necessary treatment or discharge planning activities.  Such 
 13.2   review must not be consistently conducted on a daily basis. 
 13.3      Subd. 3.  [NOTIFICATION OF DETERMINATIONS.] A utilization 
 13.4   review organization must have written procedures for providing 
 13.5   notification of its determinations on all certifications in 
 13.6   accordance with ~~the following:~~ this section. 
 13.7      Subd. 3a.  [STANDARD REVIEW DETERMINATION.] (a) 
 13.8   Notwithstanding subdivision 3b, an initial determination on all 
 13.9   requests for utilization review must be communicated to the 
 13.10  provider and enrollee in accordance with this subdivision within 
 13.11  ten business days of the request, provided that all information 
 13.12  reasonably necessary to make a determination on the request has 
 13.13  been made available to the utilization review organization.  
 13.14     (b) When an initial determination is made to certify, 
 13.15  notification must be provided promptly by telephone to the 
 13.16  provider.  The utilization review organization shall send 
 13.17  written notification to the ~~hospital, attending physician, or~~ 
 13.18  ~~applicable service provider within ten business days of the~~ 
 13.19  ~~determination in accordance with section 72A.201, subdivision~~ 
 13.20  ~~4a,~~ provider or shall maintain an audit trail of the 
 13.21  determination and telephone notification.  For purposes of this 
 13.22  subdivision, "audit trail" includes documentation of the 
 13.23  telephone notification, including the date; the name of the 
 13.24  person spoken to; the enrollee ~~or patient~~; the service, 
 13.25  procedure, or admission certified; and the date of the service, 
 13.26  procedure, or admission.  If the utilization review organization 
 13.27  indicates certification by use of a number, the number must be 
 13.28  called the "certification number." 
 13.29     ~~(b)~~ (c) When ~~a~~ an initial determination is made not to 
 13.30  certify ~~a hospital or surgical facility admission or extension~~ 
 13.31  ~~of a hospital stay, or other service requiring review~~ 
 13.32  ~~determination~~, notification must be provided by telephone within 
 13.33  one working day after making the ~~decision~~ determination to the 
 13.34  attending ~~physician~~ health care professional and hospital ~~must~~ 
 13.35  ~~be notified by telephone~~ and a written notification must be sent 
 13.36  to the hospital, attending ~~physician~~ health care professional, 
 14.1   and enrollee ~~or patient~~.  The written notification must include 
 14.2   the principal reason or reasons for the determination and the 
 14.3   process for initiating an appeal of the determination.  Upon 
 14.4   request, the utilization review organization shall provide 
 14.5   the ~~attending physician or~~ provider or enrollee with the 
 14.6   criteria used to determine the necessity, appropriateness, and 
 14.7   efficacy of the health care service and identify the database, 
 14.8   professional treatment parameter, or other basis for the 
 14.9   criteria.  Reasons for a determination not to certify may 
 14.10  include, among other things, the lack of adequate information to 
 14.11  certify after a reasonable attempt has been made to contact 
 14.12  the ~~attending physician~~ provider or enrollee. 
 14.13     (d) When an initial determination is made not to certify, 
 14.14  the written notification must inform the enrollee and the 
 14.15  attending health care professional of the right to submit an 
 14.16  appeal to the internal appeal process described in section 
 14.17  62M.06 and the procedure for initiating the internal appeal. 
 14.18     Subd. 3b.  [EXPEDITED REVIEW DETERMINATION.] (a) An 
 14.19  expedited initial determination must be utilized if the 
 14.20  attending health care professional believes that an expedited 
 14.21  determination is warranted. 
 14.22     (b) Notification of an expedited initial determination to 
 14.23  either certify or not to certify must be provided to the 
 14.24  hospital, the attending health care professional, and enrollee 
 14.25  as expeditiously as the enrollee's medical condition requires, 
 14.26  but no later than 72 hours from the initial request.  When an 
 14.27  expedited initial determination is made not to certify, the 
 14.28  utilization review organization must also notify the enrollee 
 14.29  and the attending health care professional of the right to 
 14.30  submit an appeal to the expedited internal appeal as described 
 14.31  in section 62M.06 and the procedure for initiating an internal 
 14.32  expedited appeal. 
 14.33     Subd. 4.  [FAILURE TO PROVIDE NECESSARY INFORMATION.] A 
 14.34  utilization review organization must have written procedures to 
 14.35  address the failure of a ~~health care~~ provider~~, patient, or~~ 
 14.36  ~~representative of either~~ or enrollee to provide the necessary 
 15.1   information for review.  If the ~~patient~~ enrollee or provider 
 15.2   will not release the necessary information to the utilization 
 15.3   review organization, the utilization review organization may 
 15.4   deny certification in accordance with its own policy or the 
 15.5   policy described in the health benefit plan. 
 15.6      Subd. 5.  [NOTIFICATION TO CLAIMS ADMINISTRATOR.] If the 
 15.7   utilization review organization and the claims administrator are 
 15.8   separate entities, the utilization review organization must 
 15.9   forward, electronically or in writing, a notification of 
 15.10  certification or determination not to certify to the appropriate 
 15.11  claims administrator for the health benefit plan. 
 15.12     Sec. 24.  Minnesota Statutes 1998, section 62M.06, is 
 15.13  amended to read: 
 15.14     62M.06 [APPEALS OF DETERMINATIONS NOT TO CERTIFY.] 
 15.15     Subdivision 1.  [PROCEDURES FOR APPEAL.] A utilization 
 15.16  review organization must have written procedures for appeals of 
 15.17  determinations not to certify ~~an admission, procedure, service,~~ 
 15.18  ~~or extension of stay~~.  The right to appeal must be available to 
 15.19  the enrollee ~~or designee~~ and to the attending ~~physician~~ health 
 15.20  care professional.  ~~The right of appeal must be communicated to~~ 
 15.21  ~~the enrollee or designee or to the attending physician, whomever~~ 
 15.22  ~~initiated the original certification request, at the time that~~ 
 15.23  ~~the original determination is communicated.~~ 
 15.24     Subd. 2.  [EXPEDITED APPEAL.] (a) When an initial 
 15.25  determination not to certify a health care service is made prior 
 15.26  to or during an ongoing service requiring review~~,~~ and the 
 15.27  attending ~~physician~~ health care professional believes that the 
 15.28  determination warrants ~~immediate~~ an expedited appeal, the 
 15.29  utilization review organization must ensure that the enrollee 
 15.30  and the attending ~~physician~~ health care professional, ~~enrollee,~~ 
 15.31  ~~or designee has~~ have an opportunity to appeal the determination 
 15.32  over the telephone on an expedited basis.  In such an appeal, 
 15.33  the utilization review organization must ensure reasonable 
 15.34  access to its consulting physician or health care 
 15.35  provider.  ~~Expedited appeals that are not resolved may be~~ 
 15.36  ~~resubmitted through the standard appeal process.~~ 
 16.1      (b) The utilization review organization shall notify the 
 16.2   enrollee and attending health care professional by telephone of 
 16.3   its determination on the expedited appeal as expeditiously as 
 16.4   the enrollee's medical condition requires, but no later than 72 
 16.5   hours after receiving the expedited appeal. 
 16.6      (c) If the determination not to certify is not reversed 
 16.7   through the expedited appeal, the utilization review 
 16.8   organization must include in its notification the right to 
 16.9   submit the appeal to the external appeal process described in 
 16.10  section 62Q.73 and the procedure for initiating the process.  
 16.11  This information must be provided in writing to the enrollee and 
 16.12  the attending health care professional as soon as practical. 
 16.13     Subd. 3.  [STANDARD APPEAL.] The utilization review 
 16.14  organization must establish procedures for appeals to be made 
 16.15  either in writing or by telephone. 
 16.16     (a) ~~Each~~ A utilization review organization shall notify in 
 16.17  writing the enrollee ~~or patient~~, attending ~~physician~~ health care 
 16.18  professional, and claims administrator of its determination on 
 16.19  the appeal ~~as soon as practical, but in no case later than 45~~ 
 16.20  ~~days after receiving the required documentation on the~~ 
 16.21  ~~appeal~~ within 30 days upon receipt of the notice of appeal.  
 16.22     (b) The documentation required by the utilization review 
 16.23  organization may include copies of part or all of the medical 
 16.24  record and a written statement from the attending health care 
 16.25  ~~provider~~ professional. 
 16.26     (c) Prior to upholding the ~~original decision~~ initial 
 16.27  determination not to certify for clinical reasons, the 
 16.28  utilization review organization shall conduct a review of the 
 16.29  documentation by a physician who did not make the ~~original~~ 
 16.30  initial determination not to certify. 
 16.31     (d) The process established by a utilization review 
 16.32  organization may include defining a period within which an 
 16.33  appeal must be filed to be considered.  The time period must be 
 16.34  communicated to the ~~patient,~~ enrollee~~, or~~ and attending 
 16.35  ~~physician~~ health care professional when the initial 
 16.36  determination is made. 
 17.1      (e) An attending ~~physician~~ health care professional or 
 17.2   enrollee who has been unsuccessful in an attempt to reverse a 
 17.3   determination not to certify shall, consistent with section 
 17.4   72A.285, be provided the following: 
 17.5      (1) a complete summary of the review findings; 
 17.6      (2) qualifications of the reviewers, including any license, 
 17.7   certification, or specialty designation; and 
 17.8      (3) the relationship between the enrollee's diagnosis and 
 17.9   the review criteria used as the basis for the decision, 
 17.10  including the specific rationale for the reviewer's decision. 
 17.11     (f) In cases of appeal to reverse a determination not to 
 17.12  certify for clinical reasons, the utilization review 
 17.13  organization must, upon request of the attending ~~physician~~ 
 17.14  health care professional, ensure that a physician of the 
 17.15  utilization review organization's choice in the same or a 
 17.16  similar general specialty as typically manages the medical 
 17.17  condition, procedure, or treatment under discussion is 
 17.18  reasonably available to review the case. 
 17.19     (g) If the initial determination is not reversed on appeal, 
 17.20  the utilization review organization must include in its 
 17.21  notification the right to submit the appeal to the external 
 17.22  review process described in section 62Q.73 and the procedure for 
 17.23  initiating the external process. 
 17.24     Subd. 4.  [NOTIFICATION TO CLAIMS ADMINISTRATOR.] If the 
 17.25  utilization review organization and the claims administrator are 
 17.26  separate entities, the utilization review organization 
 17.27  must ~~forward~~ notify, either electronically or in writing, ~~a~~ 
 17.28  ~~notification of certification or determination not to certify to~~ 
 17.29  the appropriate claims administrator for the health benefit plan 
 17.30  of any determination not to certify that is reversed on appeal. 
 17.31     Sec. 25.  Minnesota Statutes 1998, section 62M.07, is 
 17.32  amended to read: 
 17.33     62M.07 [PRIOR AUTHORIZATION OF SERVICES.] 
 17.34     (a) Utilization review organizations conducting prior 
 17.35  authorization of services must have written standards that meet 
 17.36  at a minimum the following requirements: 
 18.1      (1) written procedures and criteria used to determine 
 18.2   whether care is appropriate, reasonable, or medically necessary; 
 18.3      (2) a system for providing prompt notification of its 
 18.4   determinations to enrollees and providers and for notifying the 
 18.5   provider, enrollee, or enrollee's designee of appeal procedures 
 18.6   under clause (4); 
 18.7      (3) compliance with section ~~72A.201~~ 62M.05, subdivision ~~4a~~ 
 18.8   3, regarding time frames for approving and disapproving prior 
 18.9   authorization requests; 
 18.10     (4) written procedures for appeals of denials of prior 
 18.11  authorization which specify the responsibilities of the enrollee 
 18.12  and provider, and which meet the requirements of ~~section~~ 
 18.13  sections 62M.06 and 72A.285, regarding release of summary review 
 18.14  findings; and 
 18.15     (5) procedures to ensure confidentiality of 
 18.16  patient-specific information, consistent with applicable law. 
 18.17     (b) No utilization review organization, health plan 
 18.18  company, or claims administrator may conduct or require prior 
 18.19  authorization of emergency confinement or emergency treatment.  
 18.20  The enrollee or the enrollee's authorized representative may be 
 18.21  required to notify the health plan company, claims 
 18.22  administrator, or utilization review organization as soon after 
 18.23  the beginning of the emergency confinement or emergency 
 18.24  treatment as reasonably possible. 
 18.25     Sec. 26.  Minnesota Statutes 1998, section 62M.09, 
 18.26  subdivision 3, is amended to read: 
 18.27     Subd. 3.  [PHYSICIAN REVIEWER INVOLVEMENT.] A physician 
 18.28  must review all cases in which the utilization review 
 18.29  organization has concluded that a determination not to certify 
 18.30  for clinical reasons is appropriate.  The physician should be 
 18.31  reasonably available by telephone to discuss the determination 
 18.32  with the attending ~~physician~~ health care professional.  This 
 18.33  subdivision does not apply to outpatient mental health or 
 18.34  substance abuse services governed by subdivision 3a.  
 18.35     Sec. 27.  Minnesota Statutes 1998, section 62M.10, 
 18.36  subdivision 2, is amended to read: 
 19.1      Subd. 2.  [REVIEWS DURING NORMAL BUSINESS HOURS.] A 
 19.2   utilization review organization must conduct its telephone 
 19.3   reviews, on-site reviews, and hospital communications during 
 19.4   ~~hospitals' and physicians'~~ reasonable and normal business hours, 
 19.5   unless otherwise mutually agreed. 
 19.6      Sec. 28.  Minnesota Statutes 1998, section 62M.10, 
 19.7   subdivision 5, is amended to read: 
 19.8      Subd. 5.  [ORAL REQUESTS FOR INFORMATION.] Utilization 
 19.9   review organizations shall orally inform, upon request, 
 19.10  designated hospital personnel or the attending ~~physician~~ health 
 19.11  care professional of the utilization review requirements of the 
 19.12  specific health benefit plan and the general type of criteria 
 19.13  used by the review agent.  Utilization review organizations 
 19.14  should also orally inform, upon request, ~~hospitals, physicians,~~ 
 19.15  ~~and other health care professionals~~ a provider of the 
 19.16  operational procedures in order to facilitate the review process.
 19.17     Sec. 29.  Minnesota Statutes 1998, section 62M.10, 
 19.18  subdivision 7, is amended to read: 
 19.19     Subd. 7.  [AVAILABILITY OF CRITERIA.] Upon request, a 
 19.20  utilization review organization shall provide to an enrollee or 
 19.21  to ~~an attending physician or~~ a provider the criteria used for a 
 19.22  specific procedure to determine the necessity, appropriateness, 
 19.23  and efficacy of that procedure and identify the database, 
 19.24  professional treatment guideline, or other basis for the 
 19.25  criteria. 
 19.26     Sec. 30.  Minnesota Statutes 1998, section 62M.12, is 
 19.27  amended to read: 
 19.28     62M.12 [PROHIBITION OF INAPPROPRIATE INCENTIVES.] 
 19.29     No individual who is performing utilization review may 
 19.30  receive any financial incentive based on the number of denials 
 19.31  of certifications made by such individual, provided that 
 19.32  utilization review organizations may establish medically 
 19.33  appropriate performance standards.  This prohibition does not 
 19.34  apply to financial incentives established between health ~~plans~~ 
 19.35  plan companies and ~~their~~ providers. 
 19.36     Sec. 31.  Minnesota Statutes 1998, section 62M.15, is 
 20.1   amended to read: 
 20.2      62M.15 [APPLICABILITY OF OTHER CHAPTER REQUIREMENTS.] 
 20.3      The requirements of this chapter regarding the conduct of 
 20.4   utilization review are in addition to any specific requirements 
 20.5   contained in chapter 62A, 62C, 62D, 62Q, or 72A. 
 20.6      Sec. 32.  Minnesota Statutes 1998, section 62Q.106, is 
 20.7   amended to read: 
 20.8      62Q.106 [DISPUTE RESOLUTION BY COMMISSIONER.] 
 20.9      A complainant may at any time submit a complaint to the 
 20.10  appropriate commissioner to investigate.  After investigating a 
 20.11  complaint, or reviewing a company's decision, the appropriate 
 20.12  commissioner may order a remedy as authorized under ~~section~~ 
 20.13  ~~62Q.30 or~~ chapter 45, 60A, or 62D.  
 20.14     Sec. 33.  Minnesota Statutes 1998, section 62Q.19, 
 20.15  subdivision 5a, is amended to read: 
 20.16     Subd. 5a.  [COOPERATION.] Each health plan company and 
 20.17  essential community provider shall cooperate to facilitate the 
 20.18  use of the essential community provider by the high risk and 
 20.19  special needs populations.  This includes cooperation on the 
 20.20  submission and processing of claims, sharing of all pertinent 
 20.21  records and data, including performance indicators and specific 
 20.22  outcomes data, and the use of all dispute resolution methods ~~as~~ 
 20.23  ~~defined in section 62Q.11, subdivision 1~~. 
 20.24     Sec. 34.  [62Q.68] [DEFINITIONS.] 
 20.25     Subdivision 1.  [APPLICATION.] For purposes of sections 
 20.26  62Q.68 to 62Q.72, the terms defined in this section have the 
 20.27  meanings given them.  For purposes of sections 62Q.69 and 
 20.28  62Q.70, the term "health plan company" does not include an 
 20.29  insurance company licensed under chapter 60A to offer, sell, or 
 20.30  issue a policy of accident and sickness insurance as defined in 
 20.31  section 62A.01. 
 20.32     Subd. 2.  [COMPLAINT.] "Complaint" means any grievance 
 20.33  against a health plan company that is not the subject of 
 20.34  litigation and that has been submitted by a complainant to a 
 20.35  health plan company regarding the provision of health services 
 20.36  including, but not limited to, the scope of coverage for health 
 21.1   care services; retrospective denials or limitations of payment 
 21.2   for services; eligibility issues; denials, cancellations, or 
 21.3   nonrenewals of coverage; administrative operations; and the 
 21.4   quality, timeliness, and appropriateness of health care services 
 21.5   rendered.  If the complaint is from an applicant, the complaint 
 21.6   must relate to the application.  If the complaint is from a 
 21.7   former enrollee, the complaint must relate to services received 
 21.8   during the period of time the individual was an enrollee.  Any 
 21.9   grievance requiring a medical determination in its resolution 
 21.10  must be processed under the appeal procedure described in 
 21.11  section 62M.06. 
 21.12     Subd. 3.  [COMPLAINANT.] "Complainant" means an enrollee, 
 21.13  applicant, or former enrollee, or anyone acting on behalf of an 
 21.14  enrollee, applicant, or former enrollee who submits a complaint. 
 21.15     Sec. 35.  [62Q.69] [COMPLAINT RESOLUTION.] 
 21.16     Subdivision 1.  [ESTABLISHMENT.] Each health plan company 
 21.17  must establish and maintain an internal complaint resolution 
 21.18  process that meets the requirements of this section to provide 
 21.19  for the resolution of a complaint initiated by a complainant. 
 21.20     Subd. 2.  [PROCEDURES FOR FILING A COMPLAINT.] (a) A 
 21.21  complainant may submit a complaint to a health plan company 
 21.22  either by telephone or in writing.  If a complaint is submitted 
 21.23  orally and the resolution of the complaint is partially or 
 21.24  wholly adverse to the complainant, or the oral complaint is not 
 21.25  resolved by the health plan company within ten days of receiving 
 21.26  the complaint, the health plan company must inform the 
 21.27  complainant that the complaint may be submitted in writing and 
 21.28  must promptly mail a complaint form to the complainant.  The 
 21.29  complaint form must include the following information: 
 21.30     (1) the telephone number of the office of health care 
 21.31  consumer assistance, advocacy, and information, and the health 
 21.32  plan company member services or other departments or persons 
 21.33  equipped to advise complainants on complaint resolution; 
 21.34     (2) the address to which the form must be sent; 
 21.35     (3) a description of the health plan company's internal 
 21.36  complaint procedure and the applicable time limits; and 
 22.1      (4) the toll-free telephone number of either the 
 22.2   commissioner of health or commerce and notification that the 
 22.3   complainant has the right to submit the complaint at any time to 
 22.4   the appropriate commissioner for investigation. 
 22.5      (b) Upon receipt of a written complaint, the health plan 
 22.6   company must notify the complainant within ten business days 
 22.7   that the complaint was received, unless the complaint is 
 22.8   resolved to the satisfaction of the complainant within the ten 
 22.9   business days. 
 22.10     (c) At the complainant's request, a health plan company 
 22.11  must provide a complainant with any assistance needed to file a 
 22.12  written complaint. 
 22.13     (d) Each health plan company must provide, in the member 
 22.14  handbook, subscriber contract, or certification of coverage, a 
 22.15  clear and concise description of how to submit a complaint and a 
 22.16  statement that, upon request, assistance in submitting a written 
 22.17  complaint is available from the health plan company. 
 22.18     Subd. 3.  [NOTIFICATION OF COMPLAINT DECISIONS.] (a) The 
 22.19  health plan company must notify the complainant in writing of 
 22.20  its decision and the reasons for it as soon as practical but in 
 22.21  no case later than 30 days after receipt of a written complaint. 
 22.22     (b) If the decision is partially or wholly adverse to the 
 22.23  complainant, the notification must inform the complainant of the 
 22.24  right to appeal the decision to the health plan company's 
 22.25  internal appeal process described in section 62Q.70 and the 
 22.26  procedure for initiating an appeal.  
 22.27     (c) The notification must also inform the complainant of 
 22.28  the right to submit the complaint at any time to either the 
 22.29  commissioner of health or commerce for investigation and the 
 22.30  toll-free telephone number of the appropriate commissioner. 
 22.31     Sec. 36.  [62Q.70] [APPEAL OF THE COMPLAINT DECISION.] 
 22.32     Subdivision 1.  [ESTABLISHMENT.] (a) Each health plan 
 22.33  company shall establish an internal appeal process for reviewing 
 22.34  a health plan company's decision regarding a complaint filed in 
 22.35  accordance with section 62Q.69.  The appeal process must meet 
 22.36  the requirements of this section.  
 23.1      (b) The person or persons with authority to resolve or 
 23.2   recommend the resolution of the internal appeal must not be 
 23.3   solely the same person or persons who made the complaint 
 23.4   decision under section 62Q.69. 
 23.5      (c) The internal appeal process must permit the receipt of 
 23.6   testimony, correspondence, explanations, or other information 
 23.7   from the complainant, staff persons, administrators, providers, 
 23.8   or other persons as deemed necessary by the person or persons 
 23.9   investigating or presiding over the appeal. 
 23.10     Subd. 2.  [PROCEDURES FOR FILING AN APPEAL.] If a 
 23.11  complainant notifies the health plan company of the 
 23.12  complainant's desire to appeal the health plan company's 
 23.13  decision regarding the complaint through the internal appeal 
 23.14  process, the health plan company must provide the complainant 
 23.15  the option for the appeal to occur either in writing or by 
 23.16  hearing. 
 23.17     Subd. 3.  [NOTIFICATION OF APPEAL DECISIONS.] (a) Written 
 23.18  notice of the appeal decision and all key findings must be given 
 23.19  to the complainant within 30 days of the health plan company's 
 23.20  receipt of the complainant's written notice of appeal. 
 23.21     (b) If the appeal decision is partially or wholly adverse 
 23.22  to the complainant, the notice must advise the complainant of 
 23.23  the right to submit the appeal decision to the external review 
 23.24  process described in section 62Q.73 and the procedure for 
 23.25  initiating the external process. 
 23.26     (c) Upon the request of the complainant, the health plan 
 23.27  company must provide the complainant with a complete summary of 
 23.28  the appeal decision.  
 23.29     Sec. 37.  [62Q.71] [NOTICE TO ENROLLEES.] 
 23.30     Each health plan company shall provide to enrollees a clear 
 23.31  and concise description of its complaint resolution procedure, 
 23.32  if applicable under section 62Q.68, subdivision 1, and the 
 23.33  procedure used for utilization review as defined under chapter 
 23.34  62M as part of the member handbook, subscriber contract, or 
 23.35  certificate of coverage.  If the health plan company does not 
 23.36  issue a member handbook, the health plan company may provide the 
 24.1   description in another written document.  The description must 
 24.2   specifically inform enrollees:  
 24.3      (1) how to submit a complaint to the health plan company; 
 24.4      (2) if the health plan includes utilization review 
 24.5   requirements, how to notify the utilization review organization 
 24.6   in a timely manner and how to obtain certification for health 
 24.7   care services; 
 24.8      (3) how to request an appeal either through the procedures 
 24.9   described in sections 62Q.69 and 62Q.70 or through the 
 24.10  procedures described in chapter 62M; 
 24.11     (4) of the right to file a complaint with either the 
 24.12  commissioner of health or commerce at any time during the 
 24.13  complaint and appeal process; 
 24.14     (5) the toll-free telephone number of the appropriate 
 24.15  commissioner; 
 24.16     (6) the telephone number of the office of consumer 
 24.17  assistance, advocacy, and information; and 
 24.18     (7) of the right to obtain an external review under section 
 24.19  62Q.73 and a description of when and how that right may be 
 24.20  exercised. 
 24.21     Sec. 38.  [62Q.72] [RECORDKEEPING; REPORTING.] 
 24.22     Subdivision 1.  [RECORDKEEPING.] Each health plan company 
 24.23  shall maintain records of all enrollee complaints and their 
 24.24  resolutions.  These records shall be retained for five years and 
 24.25  shall be made available to the appropriate commissioner upon 
 24.26  request.  An insurance company licensed under chapter 60A may 
 24.27  instead comply with section 72A.20, subdivision 30. 
 24.28     Subd. 2.  [REPORTING.] Each health plan company shall 
 24.29  submit to the appropriate commissioner, as part of the company's 
 24.30  annual filing, data on the number and type of complaints that 
 24.31  are not resolved within 30 days, or 30 business days as provided 
 24.32  under section 72A.201, subdivision 4, clause (3), for insurance 
 24.33  companies licensed under chapter 60A.  A health plan company 
 24.34  shall also make this information available to the public upon 
 24.35  request. 
 24.36     Sec. 39. [62Q.73] [EXTERNAL REVIEW OF ADVERSE 
 25.1   DETERMINATIONS.] 
 25.2      Subdivision 1.  [DEFINITIONS.] (a) For purposes of this 
 25.3   section, the term defined in this subdivision has the meaning 
 25.4   given it. 
 25.5      (b) An adverse determination means:  
 25.6      (1) a complaint decision relating to a health care service 
 25.7   or claim that has been appealed in accordance with section 
 25.8   62Q.70 and the appeal decision is partially or wholly adverse to 
 25.9   the complainant; or 
 25.10     (2) any initial determination not to certify that has been 
 25.11  appealed in accordance with section 62M.06 and the appeal did 
 25.12  not reverse the initial determination not to certify. 
 25.13  An adverse determination does not include complaints relating to 
 25.14  fraudulent marketing practices or agent misrepresentation. 
 25.15     Subd. 2.  [RIGHT TO EXTERNAL REVIEW.] (a) Any enrollee or 
 25.16  anyone acting on behalf of an enrollee who has received an 
 25.17  adverse determination may submit a written request for an 
 25.18  external review of the adverse determination, if applicable 
 25.19  under section 62Q.68, subdivision 1, or 62M.06, to the 
 25.20  commissioner of health if the request involves a health plan 
 25.21  company regulated by that commissioner or to the commissioner of 
 25.22  commerce if the request involves a health plan company regulated 
 25.23  by that commissioner.  The written request must be accompanied 
 25.24  by a filing fee of $25.  The fee may be waived by the 
 25.25  commissioner of health or commerce in cases of financial 
 25.26  hardship. 
 25.27     (b) Nothing in this section requires the commissioner of 
 25.28  health or commerce to independently investigate an adverse 
 25.29  determination referred for independent external review. 
 25.30     (c) If an enrollee requests an external review, the health 
 25.31  plan company must participate in the external review.  The cost 
 25.32  of the external review in excess of the filing fee described in 
 25.33  paragraph (a) shall be borne by the health plan company.  
 25.34     Subd. 3.  [CONTRACT.] Pursuant to a request for proposal, 
 25.35  the commissioner of administration, in consultation with the 
 25.36  commissioners of health and commerce, shall contract with an 
 26.1   organization or business entity to provide independent external 
 26.2   reviews of all adverse determinations submitted for external 
 26.3   review.  The contract shall ensure that the fees for services 
 26.4   rendered in connection with the reviews be reasonable. 
 26.5      Subd. 4.  [CRITERIA.] The request for proposal must require 
 26.6   that the entity be affiliated with an institution of higher 
 26.7   learning and demonstrate: 
 26.8      (1) no conflicts of interest in that it is not owned, a 
 26.9   subsidiary of, or affiliated with a health plan company or 
 26.10  utilization review organization; 
 26.11     (2) an expertise in dispute resolution; 
 26.12     (3) an expertise in health related law; 
 26.13     (4) an ability to conduct reviews using a variety of 
 26.14  procedures depending upon the nature of the dispute; 
 26.15     (5) an ability to provide data to the commissioners of 
 26.16  health and commerce on reviews conducted; and 
 26.17     (6) an ability to ensure confidentiality of medical records 
 26.18  and other enrollee information. 
 26.19     Subd. 5.  [PROCESS.] (a) Upon receiving a request for an 
 26.20  external review, the external review entity must provide 
 26.21  immediate notice of the review to the enrollee and to the health 
 26.22  plan company.  Within ten business days of receiving notice of 
 26.23  the review the health plan company and the enrollee must provide 
 26.24  the external review entity with any information that they wish 
 26.25  to be considered.  Each party shall be provided an opportunity 
 26.26  to present its version of the facts and arguments.  An enrollee 
 26.27  may be assisted or represented by a person of the enrollee's 
 26.28  choice. 
 26.29     (b) As part of the external review process, an independent 
 26.30  medical opinion may be sought as necessary.  A medical review 
 26.31  panel may be used to provide additional technical expertise when 
 26.32  the issue presented is complex and clinical guidelines are 
 26.33  absent, ambiguous, unclear, or conflicting. 
 26.34     (c) An external review shall be made as soon as practical 
 26.35  but in no case later than 40 days after receiving the request 
 26.36  for an external review and must promptly send written notice of 
 27.1   the decision and the reasons for it to the enrollee, the health 
 27.2   plan company, and to the commissioner who is responsible for 
 27.3   regulating the health plan company. 
 27.4      Subd. 6.  [EFFECTS OF EXTERNAL REVIEW.] A decision rendered 
 27.5   under this section shall be nonbinding on the enrollee and 
 27.6   binding on the health plan company.  The health plan company may 
 27.7   seek judicial review of the decision on the grounds that the 
 27.8   decision was arbitrary and capricious or involved an abuse of 
 27.9   discretion. 
 27.10     Subd. 7.  [IMMUNITY FROM CIVIL LIABILITY.] A person who 
 27.11  participates in an external review by investigating, reviewing 
 27.12  materials, providing technical expertise, or rendering a 
 27.13  decision shall not be civilly liable for any action that is 
 27.14  taken in good faith, that is within the scope of the person's 
 27.15  duties, and that does not constitute willful or reckless 
 27.16  misconduct. 
 27.17     Subd. 8.  [DATA REPORTING.] The commissioners shall make 
 27.18  available to the public, upon request, summary data on the 
 27.19  decisions rendered under this section, including the number of 
 27.20  reviews heard and decided and the final outcomes.  Any data 
 27.21  released to the public must not individually identify the 
 27.22  enrollee initiating the request for external review. 
 27.23     Sec. 40.  Minnesota Statutes 1998, section 62T.04, is 
 27.24  amended to read: 
 27.25     62T.04 [COMPLAINT SYSTEM.] 
 27.26     Accountable provider networks must establish and maintain 
 27.27  an enrollee complaint system as required under ~~section~~ 
 27.28  ~~62Q.105~~ sections 62Q.68 to 62Q.72.  The accountable provider 
 27.29  network may contract with the health care purchasing alliance or 
 27.30  a vendor for operation of this system. 
 27.31     Sec. 41.  Minnesota Statutes 1998, section 72A.201, 
 27.32  subdivision 4a, is amended to read: 
 27.33     Subd. 4a.  [STANDARDS FOR PREAUTHORIZATION APPROVAL.] If a 
 27.34  policy of accident and sickness insurance or a subscriber 
 27.35  contract requires preauthorization approval for any nonemergency 
 27.36  services or benefits, the decision to approve or disapprove the 
 28.1   requested services or benefits must be ~~communicated to the~~ 
 28.2   ~~insured or the insured's health care provider within ten~~ 
 28.3   ~~business days of the preauthorization request provided that all~~ 
 28.4   ~~information reasonably necessary to make a decision on the~~ 
 28.5   ~~request has been made available to the insurer~~ processed in 
 28.6   accordance with section 62M.07. 
 28.7      Sec. 42.  Minnesota Statutes 1998, section 256B.692, 
 28.8   subdivision 2, is amended to read: 
 28.9      Subd. 2.  [DUTIES OF THE COMMISSIONER OF HEALTH.] 
 28.10  Notwithstanding chapters 62D and 62N, a county that elects to 
 28.11  purchase medical assistance and general assistance medical care 
 28.12  in return for a fixed sum without regard to the frequency or 
 28.13  extent of services furnished to any particular enrollee is not 
 28.14  required to obtain a certificate of authority under chapter 62D 
 28.15  or 62N.  A county that elects to purchase medical assistance and 
 28.16  general assistance medical care services under this section must 
 28.17  satisfy the commissioner of health that the requirements of 
 28.18  chapter 62D, applicable to health maintenance organizations, or 
 28.19  chapter 62N, applicable to community integrated service 
 28.20  networks, will be met.  A county must also assure the 
 28.21  commissioner of health that the requirements of sections 
 28.22  62J.041; 62J.48; 62J.71 to 62J.73; 62M.01 to 62M.16; all 
 28.23  applicable provisions of chapter 62Q, including sections 62Q.07; 
 28.24  62Q.075; ~~62Q.105;~~ 62Q.1055; 62Q.106; ~~62Q.11;~~ 62Q.12; 62Q.135; 
 28.25  62Q.14; 62Q.145; 62Q.19; 62Q.23, paragraph (c); ~~62Q.30;~~ 62Q.43; 
 28.26  62Q.47; 62Q.50; 62Q.52 to 62Q.56; 62Q.58; 62Q.64; 62Q.68 to 
 28.27  62Q.72; and 72A.201 will be met.  All enforcement and rulemaking 
 28.28  powers available under chapters 62D, 62J, 62M, 62N, and 62Q are 
 28.29  hereby granted to the commissioner of health with respect to 
 28.30  counties that purchase medical assistance and general assistance 
 28.31  medical care services under this section. 
 28.32     Sec. 43.  [REPEALER.] 
 28.33     (a) Minnesota Statutes 1998, section 62D.11, subdivisions 
 28.34  1b and 2, are repealed.  
 28.35     (b) Minnesota Statutes 1998, sections 62Q.105; and 62Q.30, 
 28.36  are repealed. 
 29.1      (c) Minnesota Rules, parts 4685.0100, subparts 4 and 4a; 
 29.2   and 4685.1700, are repealed. 
 29.3      (d) Minnesota Rules, part 4685.1010, subpart 3, is repealed.
 29.4      Sec. 44.  [EFFECTIVE DATE.] 
 29.5      Sections 1 to 42 and 43, paragraphs (a) and (c), are 
 29.6   effective January 1, 2000.  
 29.7      Section 43, paragraph (b), is effective July 1, 1999.