1.1                          A bill for an act 
  1.2             relating to health; requiring a utilization review 
  1.3             organization to provide patients with notification of 
  1.4             its determination; amending Minnesota Statutes 1994, 
  1.5             sections 62M.05, subdivision 3; and 72A.201, by adding 
  1.6             a subdivision. 
  1.7   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.8      Section 1.  Minnesota Statutes 1994, section 62M.05, 
  1.9   subdivision 3, is amended to read: 
  1.10     Subd 3.  [NOTIFICATION OF DETERMINATIONS.] A utilization 
  1.11  review organization must have written procedures for providing 
  1.12  notification of its determinations on all certifications in 
  1.13  accordance with the following: 
  1.14     (a) When an initial determination is made to certify, 
  1.15  notification must be provided promptly by telephone to the 
  1.16  provider.  The utilization review organization shall send 
  1.17  written notification to the hospital, attending physician, or 
  1.18  applicable service provider within ten business days of the 
  1.19  determination in accordance with section 72A.201, subdivision 
  1.20  4a, or shall maintain an audit trail of the determination and 
  1.21  telephone notification.  For purposes of this subdivision, 
  1.22  "audit trail" includes documentation of the telephone 
  1.23  notification, including the date; the name of the person spoken 
  1.24  to; the enrollee or patient; the service, procedure, or 
  1.25  admission certified; and the date of the service, procedure, or 
  1.26  admission.  If the utilization review organization indicates 
  2.1   certification by use of a number, the number must be called the 
  2.2   "certification number." 
  2.3      (b) When a determination is made not to certify a hospital 
  2.4   or surgical facility admission or extension of a hospital stay, 
  2.5   or other service requiring review determination, within one 
  2.6   working day after making the decision the attending physician 
  2.7   and hospital must be notified by telephone and a written 
  2.8   notification must be sent to the hospital, attending physician, 
  2.9   and enrollee or patient.  The written notification must include 
  2.10  the principal reason or reasons for the determination and the 
  2.11  process for initiating an appeal of the determination.  Upon 
  2.12  request, the utilization review organization shall provide the 
  2.13  attending physician or provider with the criteria used to 
  2.14  determine the necessity, appropriateness, and efficacy of the 
  2.15  health care service and identify the database, professional 
  2.16  treatment parameter, or other basis for the criteria.  Reasons 
  2.17  for a determination not to certify may include, among other 
  2.18  things, the lack of adequate information to certify after a 
  2.19  reasonable attempt has been made to contact the attending 
  2.20  physician. 
  2.21     (c) When an initial determination is made to certify and 
  2.22  the claims administrator disagrees with the determination, the 
  2.23  claims administrator shall send written notification to the 
  2.24  enrollee within ten business days of the determination or shall 
  2.25  maintain an audit trail of the determination and telephone 
  2.26  notification in accordance with section 72A.201, subdivision 4b. 
  2.27     Sec. 2.  Minnesota Statutes 1994, section 72A.201, is 
  2.28  amended by adding a subdivision to read: 
  2.29     Subd. 4b.  [NOTIFICATION.] If a policy of accident and 
  2.30  sickness insurance or a subscriber contract requires 
  2.31  preauthorization approval for any nonemergency services or 
  2.32  benefits: 
  2.33     (1) the utilization review organization makes an initial 
  2.34  determination to certify; and 
  2.35     (2) the claims administrator disagrees with the 
  2.36  determination, the claims administrator shall send written 
  3.1   notification to the enrollee within ten business days of the 
  3.2   determination or shall maintain an audit trail of the 
  3.3   determination and telephone notification.