SF 3606

Introduction - 89th Legislature (2015 - 2016)

Posted on 05/06/2016 08:47 a.m.

A bill for an act
relating to health care; modifying standards for utilization review procedures;
amending Minnesota Statutes 2014, sections 62M.04, subdivision 4; 62M.05,
subdivision 3a; 62M.06, subdivision 3; 62M.09, subdivision 3; 62M.12.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2014, section 62M.04, subdivision 4, is amended to read:

Subd. 4.

Additional information.

A utilization review organization may request
information in addition to that described in subdivision 3 when there is significant lack
of agreement between the utilization review organization and the provider regarding
the appropriateness of certification during the review or appeal process. For purposes
of this subdivision, "significant lack of agreement" means that the utilization review
organization has:

(1) tentatively determined through its professional staff that a service cannot be
certified;

(2) referred the case to a physician new text begin certified to perform the procedure new text end for review; and

(3) talked to or attempted to talk to the attending health care professional for further
information.

Nothing in sections 62M.01 to 62M.16 prohibits a utilization review organization
from requiring submission of data necessary to comply with the quality assurance and
utilization review requirements of chapter 62D or other appropriate data or outcome
analyses.

Sec. 2.

Minnesota Statutes 2014, section 62M.05, subdivision 3a, is amended to read:

Subd. 3a.

Standard review determination.

(a) Notwithstanding subdivision 3b, an
initial determination on all requests for utilization review must be communicated to the
provider and enrollee in accordance with this subdivision within ten business days of the
request, provided that all information reasonably necessary to make a determination on the
request has been made available to the utilization review organization. new text begin Failure to respond
to a request for review in accordance with this subdivision shall be deemed approved.
new text end

(b) When an initial determination is made to certify, notification must be provided
promptly by telephone to the provider. The utilization review organization shall send
written notification to the provider or shall maintain an audit trail of the determination
and telephone notification. For purposes of this subdivision, "audit trail" includes
documentation of the telephone notification, including the date; the name of the person
spoken to; the enrollee; the service, procedure, or admission certified; and the date of
the service, procedure, or admission. If the utilization review organization indicates
certification by use of a number, the number must be called the "certification number."
For purposes of this subdivision, notification may also be made by facsimile to a verified
number or by electronic mail to a secure electronic mailbox. These electronic forms of
notification satisfy the "audit trail" requirement of this paragraph.

(c) When an initial determination is made not to certify, notification must be
provided by telephone, by facsimile to a verified number, or by electronic mail to a secure
electronic mailbox within one working day after making the determination to the attending
health care professional and hospital as applicable. Written notification must also be sent
to the hospital as applicable and attending health care professional if notification occurred
by telephone. For purposes of this subdivision, notification may be made by facsimile to a
verified number or by electronic mail to a secure electronic mailbox. Written notification
must be sent to the enrollee and may be sent by United States mail, facsimile to a verified
number, or by electronic mail to a secure mailbox. The written notification must include
the principal reason or reasons for the determination and the process for initiating an appeal
of the determination. Upon request, the utilization review organization shall provide the
provider or enrollee with the criteria used to determine the necessity, appropriateness,
and efficacy of the health care service and identify the database, professional treatment
parameter, or other basis for the criteria. Reasons for a determination not to certify may
include, among other things, the lack of adequate information to certify after a reasonable
attempt has been made to contact the provider or enrollee.

(d) When an initial determination is made not to certify, the written notification must
inform the enrollee and the attending health care professional of the right to submit an
appeal to the internal appeal process described in section 62M.06 and the procedure for
initiating the internal appeal. The written notice shall be provided in a culturally and
linguistically appropriate manner consistent with the provisions of the Affordable Care
Act as defined under section 62A.011, subdivision 1a.

Sec. 3.

Minnesota Statutes 2014, section 62M.06, subdivision 3, is amended to read:

Subd. 3.

Standard appeal.

The utilization review organization must establish
procedures for appeals to be made either in writing or by telephone.

(a) A utilization review organization shall notify in writing the enrollee, attending
health care professional, and claims administrator of its determination on the appeal
within 30 days upon receipt of the notice of appeal. If the utilization review organization
cannot make a determination within 30 days due to circumstances outside the control
of the utilization review organization, the utilization review organization may take up
to 14 additional days to notify the enrollee, attending health care professional, and
claims administrator of its determination. If the utilization review organization takes any
additional days beyond the initial 30-day period to make its determination, it must inform
the enrollee, attending health care professional, and claims administrator, in advance, of
the extension and the reasons for the extension.

(b) The documentation required by the utilization review organization may include
copies of part or all of the medical record and a written statement from the attending
health care professional.

(c) Prior to upholding the initial determination not to certify for clinical reasons, the
utilization review organization shall conduct a review of the documentation by a physician
who did not make the initial determination not to certify.

(d) The process established by a utilization review organization may include
defining a period within which an appeal must be filed to be considered. The time period
must be communicated to the enrollee and attending health care professional when the
initial determination is made.

(e) An attending health care professional or enrollee who has been unsuccessful in
an attempt to reverse a determination not to certify shall, consistent with section 72A.285,
be provided the following:

(1) a complete summary of the review findings;

(2) qualifications of the reviewers, including any license, certification, or specialty
designation; and

(3) the relationship between the enrollee's diagnosis and the review criteria used as
the basis for the decision, including the specific rationale for the reviewer's decision.

(f) In cases of appeal to reverse a determination not to certify for clinical reasons,
the utilization review organization must ensure that a physician of the utilization review
organization's choice in the same or a similar specialty as typically manages the medical
condition, procedure, or treatment under discussion is deleted text begin reasonably deleted text end available to review
the case.

(g) If the initial determination is not reversed on appeal, the utilization review
organization must include in its notification the right to submit the appeal to the external
review process described in section 62Q.73 and the procedure for initiating the external
process.

Sec. 4.

Minnesota Statutes 2014, section 62M.09, subdivision 3, is amended to read:

Subd. 3.

Physician reviewer involvement.

(a) A physician new text begin certified to perform
the procedure new text end must review all cases in which the utilization review organization has
concluded that a determination not to certify for clinical reasons is appropriate.

(b) The physician conducting the review must be licensed in this state. This
paragraph does not apply to reviews conducted in connection with policies issued by a
health plan company that is assessed less than three percent of the total amount assessed
by the Minnesota Comprehensive Health Association.

(c) The physician should be reasonably available by telephone to discuss the
determination with the attending health care professional.

(d) This subdivision does not apply to outpatient mental health or substance abuse
services governed by subdivision 3a.

Sec. 5.

Minnesota Statutes 2014, section 62M.12, is amended to read:

62M.12 PROHIBITION OF INAPPROPRIATE INCENTIVES.

No individual who is performing utilization review may receive any financial
incentive based on the number of denials of certifications made by such individual deleted text begin ,
provided that utilization review organizations may establish medically appropriate
performance standards deleted text end . This prohibition does not apply to financial incentives established
between health plan companies and providers.