1.1 	A bill for an act
1.2 	relating to health care coverage; modifying requirements governing utilization 
1.3 	review and prior authorization of health care services; making conforming changes; 
1.4 	requiring a report;amending Minnesota Statutes 2018, sections 62M.01, 
1.5 	subdivisions 2, 3; 62M.02, subdivisions 2, 5, 8, 20, 21, by adding subdivisions; 
1.6 	62M.04, subdivisions 1, 2, 3, 4; 62M.05, subdivisions 3, 3a, 3b, 4, 5; 62M.06, 
1.7 	subdivisions 1, 2, 3, 4; 62M.07; 62M.09, subdivisions 3, 3a, 4, 4a, 5; 62M.10, 
1.8 	subdivision 7, by adding a subdivision; 62M.11; 62M.12; 62Q.71; 62Q.73, 
1.9 	subdivision 1; 256B.692, subdivision 2; proposing coding for new law in Minnesota 
1.10 	Statutes, chapter 62M; repealing Minnesota Statutes 2018, section 62M.02, 
1.11 	subdivision 19; Minnesota Rules, part 4685.0100, subpart 9b.
1.12 	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

1.13 	ARTICLE 1
1.14 	UTILIZATION REVIEW AND PRIOR AUTHORIZATION OF HEALTH CARE 
1.15 	SERVICES

1.16 	Section 1. Minnesota Statutes 2018, section 62M.01, subdivision 2, is amended to read:
1.17 		Subd. 2.Jurisdiction. Sections 62M.01 to 62M.16 apply This chapter applies to any 
1.18 	insurance company licensed under chapter 60A to offer, sell, or issue a policy of accident 
1.19 	and sickness insurance as defined in section 62A.01; a health service plan licensed under 
1.20 	chapter 62C; a health maintenance organization licensed under chapter 62D; the Minnesota 
1.21 	Comprehensive Health Association created under chapter 62E; a community integrated 
1.22 	service network licensed under chapter 62N; an accountable provider network operating 
1.23 	under chapter 62T; a fraternal benefit society operating under chapter 64B; a joint 
1.24 	self-insurance employee health plan operating under chapter 62H; a multiple employer 
1.25 	welfare arrangement, as defined in section 3 of the Employee Retirement Income Security 
1.26 	Act of 1974 (ERISA), United States Code, title 29, section 1103, as amended; a third-party 
2.1 	administrator licensed under section 60A.23, subdivision 8, that provides utilization review 
2.2 	services for the administration of benefits under a health benefit plan as defined in section 
2.3 	62M.02; any other entity that provides, offers, or administers hospital, outpatient, medical, 
2.4 	prescription drug, or other health benefits to individuals treated by a health professional 
2.5 	under a policy, plan, or contract; or any entity performing utilization review on behalf of a 
2.6 	business entity in this state pursuant to a health benefit plan covering a Minnesota resident.

2.7 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
2.8 	plans offered, sold, issued, or renewed on or after that date.

2.9 	Sec. 2. Minnesota Statutes 2018, section 62M.01, subdivision 3, is amended to read:
2.10 		Subd. 3.Scope. (a) Nothing in sections 62M.01 to 62M.16 applies to review of claims 
2.11 	after submission to determine eligibility for benefits under a health benefit plan. The appeal 
2.12 	procedure described in section 62M.06 applies to any complaint as defined under section 
2.13 	62Q.68, subdivision 2, that requires a medical determination in its resolution.
2.14 	(b) This chapter does not apply to managed care plans or county-based purchasing plans 
2.15 	when the plan is providing coverage to state public health care program enrollees under 
2.16 	chapter 256B or 256L.

2.17 	Sec. 3. Minnesota Statutes 2018, section 62M.02, is amended by adding a subdivision to 
2.18 	read:
2.19 		Subd. 1a.Adverse determination. "Adverse determination" means a decision by a 
2.20 	utilization review organization relating to an admission, extension of stay, or health care 
2.21 	service that is partially or wholly adverse to the enrollee, including a decision to deny an 
2.22 	admission, extension of stay, or health care service on the basis that it is not medically 
2.23 	necessary.

2.24 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
2.25 	plans offered, sold, issued, or renewed on or after that date.

2.26 	Sec. 4. Minnesota Statutes 2018, section 62M.02, subdivision 5, is amended to read:
2.27 		Subd. 5.Certification Authorization. "Certification" "Authorization" means a 
2.28 	determination by a utilization review organization that an admission, extension of stay, or 
2.29 	other health care service has been reviewed and that it, based on the information provided, 
2.30 	meets it satisfies the utilization review requirements of the applicable health plan and the 
2.31 	health plan company will then pay for the covered benefit, provided the preexisting limitation 
3.1 	provisions, the general exclusion provisions, and any deductible, co-payment, coinsurance, 
3.2 	or other policy requirements have been met.

3.3 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
3.4 	plans offered, sold, issued, or renewed on or after that date.

3.5 	Sec. 5. Minnesota Statutes 2018, section 62M.02, subdivision 8, is amended to read:
3.6 		Subd. 8.Clinical criteria. "Clinical criteria" means the written policies, decision rules, 
3.7 	clinical protocols, medical protocols, or guidelines any other criteria or rationale used by 
3.8 	the utilization review organization to determine certification whether a health care service 
3.9 	is authorized.

3.10 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
3.11 	plans offered, sold, issued, or renewed on or after that date.

3.12 	Sec. 6. Minnesota Statutes 2018, section 62M.02, is amended by adding a subdivision to 
3.13 	read:
3.14 		Subd. 10a.Emergency services. "Emergency services" has the meaning given in section 
3.15 	62Q.55, subdivision 3.

3.16 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
3.17 	plans offered, sold, issued, or renewed on or after that date.

3.18 	Sec. 7. Minnesota Statutes 2018, section 62M.02, is amended by adding a subdivision to 
3.19 	read:
3.20 		Subd. 13a.Medically necessary care. "Medically necessary care" has the meaning 
3.21 	given in section 62Q.53.

3.22 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
3.23 	plans offered, sold, issued, or renewed on or after that date.

3.24 	Sec. 8. Minnesota Statutes 2018, section 62M.02, subdivision 20, is amended to read:
3.25 		Subd. 20.Utilization review. "Utilization review" means the evaluation of the necessity, 
3.26 	appropriateness, and efficacy of the use of health care services, procedures, and facilities, 
3.27 	by a person or entity other than the attending health care professional, for the purpose of 
3.28 	determining the medical necessity of the service or admission. Utilization review also 
3.29 	includes prior authorization and review conducted after the admission of the enrollee. It 
3.30 	includes situations where the enrollee is unconscious or otherwise unable to provide advance 
4.1 	notification. Utilization review does not include a referral or participation in a referral 
4.2 	process by a participating provider unless the provider is acting as a utilization review 
4.3 	organization.

4.4 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
4.5 	plans offered, sold, issued, or renewed on or after that date.

4.6 	Sec. 9. Minnesota Statutes 2018, section 62M.02, subdivision 21, is amended to read:
4.7 		Subd. 21.Utilization review organization. "Utilization review organization" means an 
4.8 	entity including but not limited to an insurance company licensed under chapter 60A to 
4.9 	offer, sell, or issue a policy of accident and sickness insurance as defined in section 62A.01; 
4.10 	a prepaid limited health service organization issued a certificate of authority and operating 
4.11 	under sections 62A.451 to 62A.4528; a health service plan licensed under chapter 62C; a 
4.12 	health maintenance organization licensed under chapter 62D; a community integrated service 
4.13 	network licensed under chapter 62N; an accountable provider network operating under 
4.14 	chapter 62T; a fraternal benefit society operating under chapter 64B; a joint self-insurance 
4.15 	employee health plan operating under chapter 62H; a multiple employer welfare arrangement, 
4.16 	as defined in section 3 of the Employee Retirement Income Security Act of 1974 (ERISA), 
4.17 	United States Code, title 29, section 1103, as amended; a third-party administrator licensed 
4.18 	under section 60A.23, subdivision 8, which conducts utilization review and determines 
4.19 	certification of authorizes or makes adverse determinations regarding an admission, extension 
4.20 	of stay, or other health care services for a Minnesota resident; any other entity that provides, 
4.21 	offers, or administers hospital, outpatient, medical, prescription drug, or other health benefits 
4.22 	to individuals treated by a health professional under a policy, plan, or contract; or any entity 
4.23 	performing utilization review that is affiliated with, under contract with, or conducting 
4.24 	utilization review on behalf of, a business entity in this state. Utilization review organization 
4.25 	does not include a clinic or health care system acting pursuant to a written delegation 
4.26 	agreement with an otherwise regulated utilization review organization that contracts with 
4.27 	the clinic or health care system. The regulated utilization review organization is accountable 
4.28 	for the delegated utilization review activities of the clinic or health care system.

4.29 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
4.30 	plans offered, sold, issued, or renewed on or after that date.

4.31 	Sec. 10. Minnesota Statutes 2018, section 62M.05, subdivision 3a, is amended to read:
4.32 		Subd. 3a.Standard review determination. (a) Notwithstanding subdivision 3b, an 
4.33 	initial a standard review determination on all requests for utilization review must be 
5.1 	communicated to the provider and enrollee in accordance with this subdivision within ten
5.2 	five business days of after receiving the request if the request is received electronically, or 
5.3 	within six business days if received through nonelectronic means, provided that all 
5.4 	information reasonably necessary to make a determination on the request has been made 
5.5 	available to the utilization review organization. Effective January 1, 2022, a standard review 
5.6 	determination on all requests for utilization review must be communicated to the provider 
5.7 	and enrollee in accordance with this subdivision within five business days after receiving 
5.8 	the request, regardless of how the request was received, provided that all information 
5.9 	reasonably necessary to make a determination on the request has been made available to 
5.10 	the utilization review organization.
5.11 	(b) When an initial a determination is made to certify authorize, notification must be 
5.12 	provided promptly by telephone to the provider. The utilization review organization shall 
5.13 	send written notification to the provider or shall maintain an audit trail of the determination 
5.14 	and telephone notification. For purposes of this subdivision, "audit trail" includes 
5.15 	documentation of the telephone notification, including the date; the name of the person 
5.16 	spoken to; the enrollee; the service, procedure, or admission certified authorized; and the 
5.17 	date of the service, procedure, or admission. If the utilization review organization indicates 
5.18 	certification authorization by use of a number, the number must be called the "certification
5.19 	authorization number." For purposes of this subdivision, notification may also be made by 
5.20 	facsimile to a verified number or by electronic mail to a secure electronic mailbox. These 
5.21 	electronic forms of notification satisfy the "audit trail" requirement of this paragraph.
5.22 	(c) When an initial adverse determination is made not to certify, notification must be 
5.23 	provided within the time periods specified in paragraph (a) by telephone, by facsimile to a 
5.24 	verified number, or by electronic mail to a secure electronic mailbox within one working 
5.25 	day after making the determination to the attending health care professional and hospital
5.26 	or physician office as applicable. Written notification must also be sent to the hospital or 
5.27 	physician office as applicable and attending health care professional if notification occurred 
5.28 	by telephone. For purposes of this subdivision, notification may be made by facsimile to a 
5.29 	verified number or by electronic mail to a secure electronic mailbox. Written notification 
5.30 	must be sent to the enrollee and may be sent by United States mail, facsimile to a verified 
5.31 	number, or by electronic mail to a secure mailbox. The written notification must include 
5.32 	the principal reason or all reasons relied on by the utilization review organization for the 
5.33 	determination and the process for initiating an appeal of the determination. Upon request, 
5.34 	the utilization review organization shall provide the provider or enrollee with the criteria 
5.35 	used to determine the necessity, appropriateness, and efficacy of the health care service and 
6.1 	identify the database, professional treatment parameter, or other basis for the criteria. Reasons 
6.2 	for a an adverse determination not to certify may include, among other things, the lack of 
6.3 	adequate information to certify authorize after a reasonable attempt has been made to contact 
6.4 	the provider or enrollee.
6.5 	(d) When an initial adverse determination is made not to certify, the written notification 
6.6 	must inform the enrollee and the attending health care professional of the right to submit 
6.7 	an appeal to the internal appeal process described in section 62M.06 and the procedure for 
6.8 	initiating the internal appeal. The written notice shall be provided in a culturally and 
6.9 	linguistically appropriate manner consistent with the provisions of the Affordable Care Act 
6.10 	as defined under section 62A.011, subdivision 1a.

6.11 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
6.12 	plans offered, sold, issued, or renewed on or after that date.

6.13 	Sec. 11. Minnesota Statutes 2018, section 62M.05, subdivision 3b, is amended to read:
6.14 		Subd. 3b.Expedited review determination. (a) An expedited initial determination must 
6.15 	be utilized if the attending health care professional believes that an expedited determination 
6.16 	is warranted.
6.17 	(b) Notification of an expedited initial determination to either certify or not to certify
6.18 	authorize or an expedited adverse determination must be provided to the hospital, the 
6.19 	attending health care professional, and the enrollee as expeditiously as the enrollee's medical 
6.20 	condition requires, but no later than 72 48 hours from and must include at least one business 
6.21 	day after the initial request. When an expedited initial adverse determination is made not 
6.22 	to certify, the utilization review organization must also notify the enrollee and the attending 
6.23 	health care professional of the right to submit an appeal to the expedited internal appeal as 
6.24 	described in section 62M.06 and the procedure for initiating an expedited internal expedited
6.25 	appeal.

6.26 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
6.27 	plans offered, sold, issued, or renewed on or after that date.

6.28 	Sec. 12. Minnesota Statutes 2018, section 62M.05, subdivision 4, is amended to read:
6.29 		Subd. 4.Failure to provide necessary information. A utilization review organization 
6.30 	must have written procedures to address the failure of a provider or enrollee to provide the 
6.31 	necessary information for review necessary to make a determination on the request. If the 
6.32 	enrollee or provider will not release the necessary information to the utilization review 
7.1 	organization, the utilization review organization may deny certification make an adverse 
7.2 	determination in accordance with its own policy or the policy described in the health benefit 
7.3 	plan.

7.4 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
7.5 	plans offered, sold, issued, or renewed on or after that date.

7.6 	Sec. 13. Minnesota Statutes 2018, section 62M.06, subdivision 1, is amended to read:
7.7 		Subdivision 1.Procedures for appeal. (a) A utilization review organization must have 
7.8 	written procedures for appeals of determinations not to certify. The right to appeal must be 
7.9 	available to the enrollee and to the attending health care professional.
7.10 	(b) The enrollee shall be allowed to review the information relied upon in the course of 
7.11 	the appeal, present evidence and testimony as part of the appeals process, and receive 
7.12 	continued coverage pending the outcome of the appeals process. This paragraph does not 
7.13 	apply to managed care plans or county-based purchasing plans serving state public health 
7.14 	care program enrollees under section 256B.69, 256B.692, or chapter 256L, or to 
7.15 	grandfathered plans as defined under section 62A.011, subdivision 1c. Nothing in this 
7.16 	paragraph shall be construed to limit or restrict the appeal rights of state public health care 
7.17 	program enrollees provided under section 256.045 and Code of Federal Regulations, title 
7.18 	42, section 438.420(d).

7.19 	Sec. 14. Minnesota Statutes 2018, section 62M.06, subdivision 3, is amended to read:
7.20 		Subd. 3.Standard appeal. (a) The utilization review organization must establish 
7.21 	procedures for appeals to be made either in writing or by telephone.
7.22 	(b) A utilization review organization shall notify in writing the enrollee, attending health 
7.23 	care professional, and claims administrator of its determination on the appeal within 30 
7.24 	days upon 15 days after receipt of the notice of appeal. If the utilization review organization 
7.25 	cannot make a determination within 30 15 days due to circumstances outside the control of 
7.26 	the utilization review organization, the utilization review organization may take up to 14
7.27 	four additional days to notify the enrollee, attending health care professional, and claims 
7.28 	administrator of its determination. If the utilization review organization takes any additional 
7.29 	days beyond the initial 30-day 15-day period to make its determination, it must inform the 
7.30 	enrollee, attending health care professional, and claims administrator, in advance, of the 
7.31 	extension and the reasons for the extension.
8.1 	(c) The documentation required by the utilization review organization may include copies 
8.2 	of part or all of the medical record and a written statement from the attending health care 
8.3 	professional.
8.4 	(d) Prior to upholding the initial adverse determination not to certify for clinical reasons, 
8.5 	the utilization review organization shall conduct a review of the documentation by a physician 
8.6 	who did not make the initial adverse determination not to certify.
8.7 	(e) The process established by a utilization review organization may include defining a 
8.8 	period within which an appeal must be filed to be considered. The time period must be 
8.9 	communicated to the enrollee and attending health care professional when the initial adverse
8.10 	determination is made.
8.11 	(f) An attending health care professional or enrollee who has been unsuccessful in an 
8.12 	attempt to reverse a an adverse determination not to certify shall, consistent with section 
8.13 	72A.285, be provided the following:
8.14 	(1) a complete summary of the review findings;
8.15 	(2) qualifications of the reviewers, including any license, certification, or specialty 
8.16 	designation; and
8.17 	(3) the relationship between the enrollee's diagnosis and the review criteria used as the 
8.18 	basis for the decision, including the specific rationale for the reviewer's decision.
8.19 	(g) In cases of appeal to reverse a an adverse determination not to certify for clinical 
8.20 	reasons, the utilization review organization must ensure that a physician of the utilization 
8.21 	review organization's choice in the same or a similar specialty as typically manages the 
8.22 	medical condition, procedure, or treatment under discussion is reasonably available to review 
8.23 	the case.
8.24 	(h) If the initial adverse determination is not reversed on appeal, the utilization review 
8.25 	organization must include in its notification the right to submit the appeal to the external 
8.26 	review process described in section 62Q.73 and the procedure for initiating an appeal under 
8.27 	the external process.

8.28 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
8.29 	plans offered, sold, issued, or renewed on or after that date.

9.1 	Sec. 15. Minnesota Statutes 2018, section 62M.07, is amended to read:
9.2 	62M.07 PRIOR AUTHORIZATION OF SERVICES.
9.3 		Subdivision 1.Written standards. (a) Utilization review organizations conducting prior 
9.4 	authorization of services must have written standards that meet at a minimum the following 
9.5 	requirements:
9.6 	(1) written procedures and criteria used to determine whether care is appropriate, 
9.7 	reasonable, or medically necessary;
9.8 	(2) a system for providing prompt notification of its determinations to enrollees and 
9.9 	providers and for notifying the provider, enrollee, or enrollee's designee of appeal procedures 
9.10 	under clause (4);
9.11 	(3) compliance with section 62M.05, subdivisions 3a and 3b, regarding time frames for 
9.12 	approving and disapproving authorizing and making adverse determinations regarding prior 
9.13 	authorization requests;
9.14 	(4) written procedures for appeals of denials to appeal adverse determinations of prior 
9.15 	authorization requests which specify the responsibilities of the enrollee and provider, and 
9.16 	which meet the requirements of sections 62M.06 and 72A.285, regarding release of summary 
9.17 	review findings; and
9.18 	(5) procedures to ensure confidentiality of patient-specific information, consistent with 
9.19 	applicable law.
9.20 		Subd. 2.Prior authorization of emergency services prohibited. (b) No utilization 
9.21 	review organization, health plan company, or claims administrator may conduct or require 
9.22 	prior authorization of emergency confinement or an emergency treatment service. The 
9.23 	enrollee or the enrollee's authorized representative may be required to notify the health plan 
9.24 	company, claims administrator, or utilization review organization as soon as reasonably 
9.25 	possible after the beginning of the emergency confinement or emergency treatment as 
9.26 	reasonably possible service.
9.27 		Subd. 3.Retrospective revocation or limitation of prior authorization. No utilization 
9.28 	review organization, health plan company, or claims administrator may revoke, limit, 
9.29 	condition, or restrict a prior authorization that has been authorized unless there is evidence 
9.30 	that the prior authorization was authorized based on fraud or misinformation or a previously 
9.31 	approved prior authorization conflicts with state or federal law. Application of a deductible, 
9.32 	coinsurance, or other cost-sharing requirement does not constitute a limit, condition, or 
9.33 	restriction under this subdivision.
10.1 		Subd. 4.Submission of prior authorization requests. (c) If prior authorization for a 
10.2 	health care service is required, the utilization review organization, health plan company, or 
10.3 	claim administrator must allow providers to submit requests for prior authorization of the 
10.4 	health care services without unreasonable delay by telephone, facsimile, or voice mail or 
10.5 	through an electronic mechanism 24 hours a day, seven days a week. This paragraph
10.6 	subdivision does not apply to dental service covered under MinnesotaCare or medical 
10.7 	assistance.

10.8 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
10.9 	plans offered, sold, issued, or renewed on or after that date.

10.10 	Sec. 16. Minnesota Statutes 2018, section 62M.09, subdivision 3, is amended to read:
10.11 		Subd. 3.Physician reviewer involvement; adverse determinations. (a) A physician 
10.12 	must review and make the adverse determination under section 62M.05 in all cases in which 
10.13 	the utilization review organization has concluded that a an adverse determination not to 
10.14 	certify for clinical reasons is appropriate.
10.15 	(b) The physician conducting the review and making the adverse determination must be 
10.16 	licensed:
10.17 	(1) hold a current, unrestricted license to practice medicine in this state.; and
10.18 	(2) have the same or similar medical specialty as a provider that typically treats or 
10.19 	manages the condition for which the health care service has been requested.
10.20 	This paragraph does not apply to reviews conducted in connection with policies issued by 
10.21 	a health plan company that is assessed less than three percent of the total amount assessed 
10.22 	by the Minnesota Comprehensive Health Association.
10.23 	(c) The physician should be reasonably available by telephone to discuss the determination 
10.24 	with the attending health care professional.
10.25 	(d) Notwithstanding paragraph (a), a review of an adverse determination involving a 
10.26 	prescription drug must be conducted by a licensed pharmacist or physician who is competent 
10.27 	to evaluate the specific clinical issues presented in the review.
10.28 	(e) This subdivision does not apply to outpatient mental health or substance abuse services 
10.29 	governed by subdivision 3a.

10.30 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
10.31 	plans offered, sold, issued, or renewed on or after that date.

11.1 	Sec. 17. Minnesota Statutes 2018, section 62M.10, subdivision 7, is amended to read:
11.2 		Subd. 7.Availability of criteria. Upon request, (a) For utilization review determinations 
11.3 	other than prior authorization, a utilization review organization shall, upon request, provide 
11.4 	to an enrollee, a provider, and the commissioner of commerce the criteria used to determine 
11.5 	the medical necessity, appropriateness, and efficacy of a procedure or service and identify 
11.6 	the database, professional treatment guideline, or other basis for the criteria.
11.7 	(b) For prior authorization determinations, a utilization review organization must submit 
11.8 	the organization's current prior authorization requirements and restrictions, including written, 
11.9 	evidence-based, clinical criteria used to make an authorization or adverse determination, to 
11.10 	all health plan companies for which the organization performs utilization review. A health 
11.11 	plan company must post on its public website the prior authorization requirements and 
11.12 	restrictions of any utilization review organization that performs utilization review for the 
11.13 	health plan company. These prior authorization requirements and restrictions must be detailed 
11.14 	and written in language that is easily understandable to providers.

11.15 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
11.16 	plans offered, sold, issued, or renewed on or after that date.

11.17 	Sec. 18. Minnesota Statutes 2018, section 62M.10, is amended by adding a subdivision 
11.18 	to read:
11.19 		Subd. 8.Notice; new prior authorization requirements or restrictions; change to 
11.20 	existing requirement or restriction. (a) Before a utilization review organization may 
11.21 	implement a new prior authorization requirement or restriction or amend an existing prior 
11.22 	authorization requirement or restriction, the utilization review organization must submit the 
11.23 	new or amended requirement or restriction to all health plan companies for which the 
11.24 	organization performs utilization review. A health plan company must post on its website 
11.25 	the new or amended requirement or restriction.
11.26 	(b) At least 45 days before a new prior authorization requirement or restriction or an 
11.27 	amended existing prior authorization requirement or restriction is implemented, the utilization 
11.28 	review organization, health plan company, or claims administrator must provide written or 
11.29 	electronic notice of the new or amended requirement or restriction to all Minnesota-based, 
11.30 	in-network attending health care professionals who are subject to the prior authorization 
11.31 	requirements and restrictions.

11.32 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
11.33 	plans offered, sold, issued, or renewed on or after that date.

12.1 	Sec. 19. [62M.17] CONTINUITY OF CARE; PRIOR AUTHORIZATIONS.
12.2 		Subdivision 1.Compliance with prior authorization approved by previous utilization 
12.3 	review organization; change in health plan company. If an enrollee obtains coverage 
12.4 	from a new health plan company and the health plan company for the enrollee's new health 
12.5 	benefit plan uses a different utilization review organization from the enrollee's previous 
12.6 	health benefit plan to conduct utilization review, the health plan company for the enrollee's 
12.7 	new health benefit plan shall comply with a prior authorization for health care services 
12.8 	approved by the utilization review organization used by the enrollee's previous health benefit 
12.9 	plan for at least the first 60 days that the enrollee is covered under the new health benefit 
12.10 	plan. In order to obtain coverage for this 60-day time period, the enrollee or the enrollee's 
12.11 	attending health care professional must submit documentation of the previous prior 
12.12 	authorization to the enrollee's new health plan company according to procedures in the 
12.13 	enrollee's new health benefit plan. During this 60-day time period, the utilization review 
12.14 	organization used by the enrollee's new health plan company may conduct its own utilization 
12.15 	review of these health care services.
12.16 		Subd. 2.Effect of change in prior authorization clinical criteria. (a) If, during a plan 
12.17 	year, a utilization review organization changes coverage terms for a health care service or 
12.18 	the clinical criteria used to conduct prior authorizations for a health care service, the change 
12.19 	in coverage terms or change in clinical criteria shall not apply until the next plan year for 
12.20 	any enrollee who received prior authorization for a health care service using the coverage 
12.21 	terms or clinical criteria in effect before the effective date of the change.
12.22 	(b) Paragraph (a) does not apply if a utilization review organization  changes coverage 
12.23 	terms for a drug or device that has been deemed unsafe by the United States Food and Drug 
12.24 	Administration (FDA); that has been withdrawn by either the FDA or the product 
12.25 	manufacturer; or when an independent source of research, clinical guidelines, or 
12.26 	evidence-based standards has issued drug- or device-specific warnings or recommended 
12.27 	changes in drug or device usage.
12.28 	(c) Paragraph (a) does not apply if a utilization review organization  changes coverage 
12.29 	terms for a service or the clinical criteria used to conduct prior authorizations for a service 
12.30 	when an independent source of research, clinical guidelines, or evidence-based standards 
12.31 	has recommended changes in usage of the service for reasons related to patient harm.
12.32 	(d) Paragraph (a) does not apply if a utilization review organization  removes a brand 
12.33 	name drug from its formulary or places a brand name drug in a benefit category that increases 
12.34 	the enrollee's cost, provided the utilization review organization (1) adds to its formulary a 
13.1 	generic or multisource brand name drug rated as therapeutically equivalent according to 
13.2 	the FDA Orange Book, or a biologic drug rated as interchangeable according to the FDA 
13.3 	Purple Book, at a lower cost to the enrollee, and (2) provides at least a 60-day notice to 
13.4 	prescribers, pharmacists, and affected enrollees.

13.5 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
13.6 	plans offered, sold, issued, or renewed on or after that date.

13.7 	Sec. 20. [62M.18] ANNUAL POSTING ON WEBSITE; PRIOR AUTHORIZATIONS.
13.8 	(a) By April 1, 2022, and each April 1 thereafter, a health plan company must post on 
13.9 	the health plan company's public website the following data for the immediately preceding 
13.10 	calendar year for each commercial product:
13.11 	(1) the number of prior authorization requests for which an authorization was issued;
13.12 	(2) the number of prior authorization requests for which an adverse determination was 
13.13 	issued and sorted by: (i) health care service; (ii) whether the adverse determination was 
13.14 	appealed; and (iii) whether the adverse determination was upheld or reversed on appeal;
13.15 	(3) the number of prior authorization requests that were submitted electronically and 
13.16 	not by facsimile or e-mail or other method pursuant to section 62J.497; and
13.17 	(4) the reasons for prior authorization denial including but not limited to:
13.18 	(i) patient did not meet prior authorization criteria;
13.19 	(ii) incomplete information submitted by the provider to the utilization review 
13.20 	organization;
13.21 	(iii) change in treatment program; and
13.22 	(iv) the patient is no longer covered by the plan.
13.23 	(b) All information posted under this section must be written in easily understandable 
13.24 	language.

13.25 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
13.26 	plans offered, sold, issued, or renewed on or after that date.

13.27 	Sec. 21. COMPLIANCE REPORT ON DRUG PRIOR AUTHORIZATION.
 13.28 	By February 1, 2021, the commissioner of health shall submit to the chairs and ranking 
13.29 	minority members of the legislative committees with jurisdiction over health care policy 
13.30 	and finance a report on compliance with the requirements for providers in Minnesota Statutes, 
14.1 	section 62J.497, subdivision 5. The report must include the following information from 
14.2 	health plans offered in the commercial fully insured and self-insured health insurance 
14.3 	markets:
14.4 	(1) the total number of drug prior authorization requests;
14.5 	(2) the frequency with which drug prior authorization requests are submitted 
14.6 	electronically. Electronic submission does not include facsimile or e-mail requests;
14.7 	(3) the turnaround times for health plans when drug prior authorizations are submitted 
14.8 	electronically;
14.9 	(4) the turnaround times for health plans when drug prior authorizations are not submitted 
14.10 	electronically;
14.11 	(5) the reasons electronic drug prior authorizations are denied;
14.12 	(6) the reasons nonelectronic drug prior authorizations are denied;
14.13 	(7) the anticipated effect on denials and turnaround times if all providers in Minnesota 
14.14 	were to submit drug prior authorizations electronically;
14.15 	(8) the differences between the commercial fully insured and self-insured markets for 
14.16 	clauses (1) to (7); and
14.17 	(9) the reasons providers are not able to comply with Minnesota Statutes, section 62J.497, 
14.18 	subdivision 5.

14.19 	Sec. 22. REPEALER.
 14.20 	(a) Minnesota Statutes 2018, section 62M.02, subdivision 19, is repealed effective 
14.21 	January 1, 2021.
14.22 	(b) Minnesota Rules, part 4685.0100, subpart 9b, is repealed effective January 1, 2021.

14.23 	ARTICLE 2
14.24 	CONFORMING CHANGES

14.25 	Section 1. Minnesota Statutes 2018, section 62M.02, subdivision 2, is amended to read:
14.26 		Subd. 2.Appeal. "Appeal" means a formal request, either orally or in writing, to 
14.27 	reconsider a an adverse determination not to certify regarding an admission, extension of 
14.28 	stay, or other health care service.

14.29 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
14.30 	plans offered, sold, issued, or renewed on or after that date.

15.1 	Sec. 2. Minnesota Statutes 2018, section 62M.04, subdivision 1, is amended to read:
15.2 		Subdivision 1.Responsibility for obtaining certification authorization. A health 
15.3 	benefit plan that includes utilization review requirements must specify the process for 
15.4 	notifying the utilization review organization in a timely manner and obtaining certification
15.5 	authorization for health care services. Each health plan company must provide a clear and 
15.6 	concise description of this process to an enrollee as part of the policy, subscriber contract, 
15.7 	or certificate of coverage. In addition to the enrollee, the utilization review organization 
15.8 	must allow any provider or provider's designee, or responsible patient representative, 
15.9 	including a family member, to fulfill the obligations under the health plan.
15.10 	A claims administrator that contracts directly with providers for the provision of health 
15.11 	care services to enrollees may, through contract, require the provider to notify the review 
15.12 	organization in a timely manner and obtain certification authorization for health care services.

15.13 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
15.14 	plans offered, sold, issued, or renewed on or after that date.

15.15 	Sec. 3. Minnesota Statutes 2018, section 62M.04, subdivision 2, is amended to read:
15.16 		Subd. 2.Information upon which utilization review is conducted. (a) If the utilization 
15.17 	review organization is conducting routine prospective and concurrent utilization review, 
15.18 	utilization review organizations must collect only the information necessary to certify
15.19 	authorize the admission, procedure of treatment, and length of stay.
15.20 	(b) Utilization review organizations may request, but may not require providers to supply,
15.21 	numerically encoded diagnoses or procedures as part of the certification authorization
15.22 	process.
15.23 	(c) Utilization review organizations must not routinely request copies of medical records 
15.24 	for all patients reviewed. In performing prospective and concurrent review, copies of the 
15.25 	pertinent portion of the medical record should be required only when a difficulty develops 
15.26 	in certifying authorizing the medical necessity or appropriateness of the admission or 
15.27 	extension of stay.
15.28 	(d) Utilization review organizations may request copies of medical records retrospectively 
15.29 	for a number of purposes, including auditing the services provided, quality assurance review, 
15.30 	ensuring compliance with the terms of either the health benefit plan or the provider contract, 
15.31 	and compliance with utilization review activities. Except for reviewing medical records 
15.32 	associated with an appeal or with an investigation or audit of data discrepancies, providers 
15.33 	must be reimbursed for the reasonable costs of duplicating records requested by the utilization 
16.1 	review organization for retrospective review unless otherwise provided under the terms of 
16.2 	the provider contract.

16.3 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
16.4 	plans offered, sold, issued, or renewed on or after that date.

16.5 	Sec. 4. Minnesota Statutes 2018, section 62M.04, subdivision 3, is amended to read:
16.6 		Subd. 3.Data elements. (a) Except as otherwise provided in sections 62M.01 to 62M.16
16.7 	this chapter, for purposes of certification authorization a utilization review organization 
16.8 	must limit its data requirements to the following elements:
16.9 	(b) Patient information that includes the following:
16.10 	(1) name;
16.11 	(2) address;
16.12 	(3) date of birth;
16.13 	(4) sex;
16.14 	(5) Social Security number or patient identification number;
16.15 	(6) name of health plan company or health plan; and
16.16 	(7) plan identification number.
16.17 	(c) Enrollee information that includes the following:
16.18 	(1) name;
16.19 	(2) address;
16.20 	(3) Social Security number or employee identification number;
16.21 	(4) relation to patient;
16.22 	(5) employer;
16.23 	(6) health benefit plan;
16.24 	(7) group number or plan identification number; and
16.25 	(8) availability of other coverage.
16.26 	(d) Attending health care professional information that includes the following:
16.27 	(1) name;
16.28 	(2) address;
17.1 	(3) telephone numbers;
17.2 	(4) degree and license;
17.3 	(5) specialty or board certification status; and
17.4 	(6) tax identification number or other identification number.
17.5 	(e) Diagnosis and treatment information that includes the following:
17.6 	(1) primary diagnosis with associated ICD or DSM coding, if available;
17.7 	(2) secondary diagnosis with associated ICD or DSM coding, if available;
17.8 	(3) tertiary diagnoses with associated ICD or DSM coding, if available;
17.9 	(4) proposed procedures or treatments with ICD or associated CPT codes, if available;
17.10 	(5) surgical assistant requirement;
17.11 	(6) anesthesia requirement;
17.12 	(7) proposed admission or service dates;
17.13 	(8) proposed procedure date; and
17.14 	(9) proposed length of stay.
17.15 	(f) Clinical information that includes the following:
17.16 	(1) support and documentation of appropriateness and level of service proposed; and
17.17 	(2) identification of contact person for detailed clinical information.
17.18 	(g) Facility information that includes the following:
17.19 	(1) type;
17.20 	(2) licensure and certification status and DRG exempt status;
17.21 	(3) name;
17.22 	(4) address;
17.23 	(5) telephone number; and
17.24 	(6) tax identification number or other identification number.
17.25 	(h) Concurrent or continued stay review information that includes the following:
17.26 	(1) additional days, services, or procedures proposed;
18.1 	(2) reasons for extension, including clinical information sufficient for support of 
18.2 	appropriateness and level of service proposed; and
18.3 	(3) diagnosis status.
18.4 	(i) For admissions to facilities other than acute medical or surgical hospitals, additional 
18.5 	information that includes the following:
18.6 	(1) history of present illness;
18.7 	(2) patient treatment plan and goals;
18.8 	(3) prognosis;
18.9 	(4) staff qualifications; and
18.10 	(5) 24-hour availability of staff.
18.11 	Additional information may be required for other specific review functions such as 
18.12 	discharge planning or catastrophic case management. Second opinion information may also 
18.13 	be required, when applicable, to support benefit plan requirements.

18.14 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
18.15 	plans offered, sold, issued, or renewed on or after that date.

18.16 	Sec. 5. Minnesota Statutes 2018, section 62M.04, subdivision 4, is amended to read:
18.17 		Subd. 4.Additional information. A utilization review organization may request 
18.18 	information in addition to that described in subdivision 3 when there is significant lack of 
18.19 	agreement between the utilization review organization and the provider regarding the 
18.20 	appropriateness of certification authorization during the review or appeal process. For 
18.21 	purposes of this subdivision, "significant lack of agreement" means that the utilization 
18.22 	review organization has:
18.23 	(1) tentatively determined through its professional staff that a service cannot be certified
18.24 	authorized;
18.25 	(2) referred the case to a physician for review; and
18.26 	(3) talked to or attempted to talk to the attending health care professional for further 
18.27 	information.
18.28 	Nothing in sections 62M.01 to 62M.16 this chapter prohibits a utilization review 
18.29 	organization from requiring submission of data necessary to comply with the quality 
18.30 	assurance and utilization review requirements of chapter 62D or other appropriate data or 
18.31 	outcome analyses.

19.1 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
19.2 	plans offered, sold, issued, or renewed on or after that date.

19.3 	Sec. 6. Minnesota Statutes 2018, section 62M.05, subdivision 3, is amended to read:
19.4 		Subd. 3.Notification of adverse determinations and authorizations. A utilization 
19.5 	review organization must have written procedures for providing notification of its 
19.6 	determinations on all certifications its adverse determinations and authorizations in 
19.7 	accordance with this section.

19.8 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
19.9 	plans offered, sold, issued, or renewed on or after that date.

19.10 	Sec. 7. Minnesota Statutes 2018, section 62M.05, subdivision 5, is amended to read:
19.11 		Subd. 5.Notification to claims administrator. If the utilization review organization 
19.12 	and the claims administrator are separate entities, the utilization review organization must 
19.13 	forward, electronically or in writing, a notification of certification or determination not to 
19.14 	certify an authorization or adverse determination to the appropriate claims administrator 
19.15 	for the health benefit plan. If it is determined by the claims administrator that the certified
19.16 	authorized health care service is not covered by the health benefit plan, the claims 
19.17 	administrator must promptly notify the claimant and provider of this information.

19.18 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
19.19 	plans offered, sold, issued, or renewed on or after that date.

19.20 	Sec. 8. Minnesota Statutes 2018, section 62M.06, subdivision 1, is amended to read:
19.21 		Subdivision 1.Procedures for appeal. (a) A utilization review organization must have 
19.22 	written procedures for appeals of adverse determinations not to certify. The right to appeal 
19.23 	must be available to the enrollee and to the attending health care professional.
19.24 	(b) The enrollee shall be allowed to review the information relied upon in the course of 
19.25 	the appeal, present evidence and testimony as part of the appeals process, and receive 
19.26 	continued coverage pending the outcome of the appeals process. This paragraph does not 
19.27 	apply to managed care plans or county-based purchasing plans serving state public health 
19.28 	care program enrollees under section 256B.69, 256B.692, or chapter 256L, or to 
19.29 	grandfathered plans as defined under section 62A.011, subdivision 1c. Nothing in this 
19.30 	paragraph shall be construed to limit or restrict the appeal rights of state public health care 
19.31 	program enrollees provided under section 256.045 and Code of Federal Regulations, title 
19.32 	42, section 438.420(d).

20.1 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
20.2 	plans offered, sold, issued, or renewed on or after that date.

20.3 	Sec. 9. Minnesota Statutes 2018, section 62M.06, subdivision 2, is amended to read:
20.4 		Subd. 2.Expedited appeal. (a) When an initial adverse determination not to certify for
20.5 	a health care service is made prior to or during an ongoing service requiring review and the 
20.6 	attending health care professional believes that the determination warrants an expedited 
20.7 	appeal, the utilization review organization must ensure that the enrollee and the attending 
20.8 	health care professional have an opportunity to appeal the determination over the telephone 
20.9 	on an expedited basis. In such an appeal, the utilization review organization must ensure 
20.10 	reasonable access to its consulting physician or health care provider.
20.11 	(b) The utilization review organization shall notify the enrollee and attending health 
20.12 	care professional by telephone of its determination on the expedited appeal as expeditiously 
20.13 	as the enrollee's medical condition requires, but no later than 72 hours after receiving the 
20.14 	expedited appeal.
20.15 	(c) If the adverse determination not to certify is not reversed through the expedited 
20.16 	appeal, the utilization review organization must include in its notification the right to submit 
20.17 	the appeal to the external appeal process described in section 62Q.73 and the procedure for 
20.18 	initiating the process. This information must be provided in writing to the enrollee and the 
20.19 	attending health care professional as soon as practical.

20.20 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
20.21 	plans offered, sold, issued, or renewed on or after that date.

20.22 	Sec. 10. Minnesota Statutes 2018, section 62M.06, subdivision 4, is amended to read:
20.23 		Subd. 4.Notification to claims administrator. If the utilization review organization 
20.24 	and the claims administrator are separate entities, the utilization review organization must 
20.25 	notify, either electronically or in writing, the appropriate claims administrator for the health 
20.26 	benefit plan of any adverse determination not to certify that is reversed on appeal.

20.27 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
20.28 	plans offered, sold, issued, or renewed on or after that date.

20.29 	Sec. 11. Minnesota Statutes 2018, section 62M.09, subdivision 3a, is amended to read:
20.30 		Subd. 3a.Mental health and substance abuse reviews. (a) A peer of the treating mental 
20.31 	health or substance abuse provider, a doctoral-level psychologist, or a physician must review 
21.1 	requests for outpatient services in which the utilization review organization has concluded 
21.2 	that a an adverse determination not to certify for a mental health or substance abuse service 
21.3 	for clinical reasons is appropriate, provided that any final adverse determination not to 
21.4 	certify issued under section 62M.05 for a treatment is made by a psychiatrist certified by 
21.5 	the American Board of Psychiatry and Neurology and appropriately licensed in this state 
21.6 	or by a doctoral-level psychologist licensed in this state.
21.7 	(b) Notwithstanding paragraph (a), a doctoral-level psychologist shall not review any 
21.8 	request or final adverse determination not to certify for a mental health or substance abuse 
21.9 	service or treatment if the treating provider is a psychiatrist.
21.10 	(c) Notwithstanding the notification requirements of section 62M.05, a utilization review 
21.11 	organization that has made an initial decision an adverse determination to certify authorize
21.12 	in accordance with the requirements of section 62M.05 may elect to provide notification of 
21.13 	a determination to continue coverage through facsimile or mail.
21.14 	(d) This subdivision does not apply to determinations made in connection with policies 
21.15 	issued by a health plan company that is assessed less than three percent of the total amount 
21.16 	assessed by the Minnesota Comprehensive Health Association.

21.17 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
21.18 	plans offered, sold, issued, or renewed on or after that date.

21.19 	Sec. 12. Minnesota Statutes 2018, section 62M.09, subdivision 4, is amended to read:
21.20 		Subd. 4.Dentist plan reviews. A dentist must review all cases in which the utilization 
21.21 	review organization has concluded that a an adverse determination not to certify for a dental 
21.22 	service or procedure for clinical reasons is appropriate and an appeal has been made by the 
21.23 	attending dentist, enrollee, or designee.

21.24 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
21.25 	plans offered, sold, issued, or renewed on or after that date.

21.26 	Sec. 13. Minnesota Statutes 2018, section 62M.09, subdivision 4a, is amended to read:
21.27 		Subd. 4a.Chiropractic review. A chiropractor must review all cases in which the 
21.28 	utilization review organization has concluded that a an adverse determination not to certify
21.29 	for a chiropractic service or procedure for clinical reasons is appropriate and an appeal has 
21.30 	been made by the attending chiropractor, enrollee, or designee.

21.31 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
21.32 	plans offered, sold, issued, or renewed on or after that date.

22.1 	Sec. 14. Minnesota Statutes 2018, section 62M.09, subdivision 5, is amended to read:
22.2 		Subd. 5.Written clinical criteria. A utilization review organization's decisions must 
22.3 	be supported by written clinical criteria and review procedures. Clinical criteria and review 
22.4 	procedures must be established with appropriate involvement from actively practicing 
22.5 	physicians. A utilization review organization must use written clinical criteria, as required, 
22.6 	for determining the appropriateness of the certification authorization request. The utilization 
22.7 	review organization must have a procedure for ensuring, at a minimum, the annual evaluation 
22.8 	and updating of the written criteria based on sound clinical principles.

22.9 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
22.10 	plans offered, sold, issued, or renewed on or after that date.

22.11 	Sec. 15. Minnesota Statutes 2018, section 62M.11, is amended to read:
22.12 	62M.11 COMPLAINTS TO COMMERCE OR HEALTH.
22.13 	Notwithstanding the provisions of sections 62M.01 to 62M.16 this chapter, an enrollee 
22.14 	may file a complaint regarding a an adverse determination not to certify directly to the 
22.15 	commissioner responsible for regulating the utilization review organization.

22.16 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
22.17 	plans offered, sold, issued, or renewed on or after that date.

22.18 	Sec. 16. Minnesota Statutes 2018, section 62M.12, is amended to read:
22.19 	62M.12 PROHIBITION OF INAPPROPRIATE INCENTIVES.
22.20 	No individual who is performing utilization review may receive any financial incentive 
22.21 	based on the number of denials of certifications adverse determinations made by such 
22.22 	individual, provided that utilization review organizations may establish medically appropriate 
22.23 	performance standards. This prohibition does not apply to financial incentives established 
22.24 	between health plan companies and providers.

22.25 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
22.26 	plans offered, sold, issued, or renewed on or after that date.

22.27 	Sec. 17. Minnesota Statutes 2018, section 62Q.71, is amended to read:
22.28 	62Q.71 NOTICE TO ENROLLEES.
22.29 	Each health plan company shall provide to enrollees a clear and concise description of 
22.30 	its complaint resolution procedure, if applicable under section 62Q.68, subdivision 1, and 
23.1 	the procedure used for utilization review as defined under chapter 62M as part of the member 
23.2 	handbook, subscriber contract, or certificate of coverage. If the health plan company does 
23.3 	not issue a member handbook, the health plan company may provide the description in 
23.4 	another written document. The description must specifically inform enrollees:
23.5 	(1) how to submit a complaint to the health plan company;
23.6 	(2) if the health plan includes utilization review requirements, how to notify the utilization 
23.7 	review organization in a timely manner and how to obtain certification authorization for 
23.8 	health care services;
23.9 	(3) how to request an appeal either through the procedures described in section 62Q.70, 
23.10 	if applicable, or through the procedures described in chapter 62M;
23.11 	(4) of the right to file a complaint with either the commissioner of health or commerce 
23.12 	at any time during the complaint and appeal process;
23.13 	(5) of the toll-free telephone number of the appropriate commissioner; and
23.14 	(6) of the right, for individual and group coverage, to obtain an external review under 
23.15 	section 62Q.73 and a description of when and how that right may be exercised, including 
23.16 	that under most circumstances an enrollee must exhaust the internal complaint or appeal 
23.17 	process prior to external review. However, an enrollee may proceed to external review 
23.18 	without exhausting the internal complaint or appeal process under the following 
23.19 	circumstances:
23.20 	(i) the health plan company waives the exhaustion requirement;
23.21 	(ii) the health plan company is considered to have waived the exhaustion requirement 
23.22 	by failing to substantially comply with any requirements including, but not limited to, time 
23.23 	limits for internal complaints or appeals; or
23.24 	(iii) the enrollee has applied for an expedited external review at the same time the enrollee 
23.25 	qualifies for and has applied for an expedited internal review under chapter 62M.

23.26 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
23.27 	plans offered, sold, issued, or renewed on or after that date.

23.28 	Sec. 18. Minnesota Statutes 2018, section 62Q.73, subdivision 1, is amended to read:
23.29 		Subdivision 1.Definition. For purposes of this section, "adverse determination" means:
23.30 	(1) for individual health plans, a complaint decision relating to a health care service or 
23.31 	claim that is partially or wholly adverse to the complainant;
24.1 	(2) an individual health plan that is grandfathered plan coverage may instead apply the 
24.2 	definition of adverse determination for group coverage in clause (3);
24.3 	(3) for group health plans, a complaint decision relating to a health care service or claim 
24.4 	that has been appealed in accordance with section 62Q.70 and the appeal decision is partially 
24.5 	or wholly adverse to the complainant;
24.6 	(4) any initial adverse determination not to certify, as defined in section 62M.02, 
24.7 	subdivision 1a, that has been appealed in accordance with section 62M.06 and the appeal 
24.8 	did not reverse the initial adverse determination not to certify;
24.9 	(5) a decision relating to a health care service made by a health plan company licensed 
24.10 	under chapter 60A that denies the service on the basis that the service was not medically 
24.11 	necessary; or
24.12 	(6) the enrollee has met the requirements of subdivision 6, paragraph (e).
24.13 	An adverse determination does not include complaints relating to fraudulent marketing 
24.14 	practices or agent misrepresentation.

24.15 	EFFECTIVE DATE. This section is effective January 1, 2021, and applies to health 
24.16 	plans offered, sold, issued, or renewed on or after that date.

24.17 	Sec. 19. Minnesota Statutes 2018, section 256B.692, subdivision 2, is amended to read:
24.18 		Subd. 2.Duties of commissioner of health. (a) Notwithstanding chapters 62D and 62N, 
24.19 	a county that elects to purchase medical assistance in return for a fixed sum without regard 
24.20 	to the frequency or extent of services furnished to any particular enrollee is not required to 
24.21 	obtain a certificate of authority under chapter 62D or 62N. The county board of 
24.22 	commissioners is the governing body of a county-based purchasing program. In a multicounty 
24.23 	arrangement, the governing body is a joint powers board established under section 471.59.
24.24 	(b) A county that elects to purchase medical assistance services under this section must 
24.25 	satisfy the commissioner of health that the requirements for assurance of consumer protection, 
24.26 	provider protection, and fiscal solvency of chapter 62D, applicable to health maintenance 
24.27 	organizations will be met according to the following schedule:
24.28 	(1) for a county-based purchasing plan approved on or before June 30, 2008, the plan 
24.29 	must have in reserve:
24.30 	(i) at least 50 percent of the minimum amount required under chapter 62D as of January 
24.31 	1, 2010;
25.1 	(ii) at least 75 percent of the minimum amount required under chapter 62D as of January 
25.2 	1, 2011;
25.3 	(iii) at least 87.5 percent of the minimum amount required under chapter 62D as of 
25.4 	January 1, 2012; and
25.5 	(iv) at least 100 percent of the minimum amount required under chapter 62D as of January 
25.6 	1, 2013; and
25.7 	(2) for a county-based purchasing plan first approved after June 30, 2008, the plan must 
25.8 	have in reserve:
25.9 	(i) at least 50 percent of the minimum amount required under chapter 62D at the time 
25.10 	the plan begins enrolling enrollees;
25.11 	(ii) at least 75 percent of the minimum amount required under chapter 62D after the first 
25.12 	full calendar year;
25.13 	(iii) at least 87.5 percent of the minimum amount required under chapter 62D after the 
25.14 	second full calendar year; and
25.15 	(iv) at least 100 percent of the minimum amount required under chapter 62D after the 
25.16 	third full calendar year.
25.17 	(c) Until a plan is required to have reserves equaling at least 100 percent of the minimum 
25.18 	amount required under chapter 62D, the plan may demonstrate its ability to cover any losses 
25.19 	by satisfying the requirements of chapter 62N. A county-based purchasing plan must also 
25.20 	assure the commissioner of health that the requirements of sections 62J.041; 62J.48; 62J.71
25.21 	to 62J.73; 62M.01 to 62M.16; all applicable provisions of chapter 62Q, including sections 
25.22 	62Q.075; 62Q.1055; 62Q.106; 62Q.12; 62Q.135; 62Q.14; 62Q.145; 62Q.19; 62Q.23, 
25.23 	paragraph (c); 62Q.43; 62Q.47; 62Q.50; 62Q.52 to 62Q.56; 62Q.58; 62Q.68 to 62Q.72; 
25.24 	and 72A.201 will be met.
25.25 	(d) All enforcement and rulemaking powers available under chapters 62D, 62J, 62M,
25.26 	62N, and 62Q are hereby granted to the commissioner of health with respect to counties 
25.27 	that purchase medical assistance services under this section.
25.28 	(e) The commissioner, in consultation with county government, shall develop 
25.29 	administrative and financial reporting requirements for county-based purchasing programs 
25.30 	relating to sections 62D.041, 62D.042, 62D.045, 62D.08, 62N.28, 62N.29, and 62N.31, 
25.31 	and other sections as necessary, that are specific to county administrative, accounting, and 
25.32 	reporting systems and consistent with other statutory requirements of counties.
26.1 	(f) The commissioner shall collect from a county-based purchasing plan under this 
26.2 	section the following fees:
26.3 	(1) fees attributable to the costs of audits and other examinations of plan financial 
26.4 	operations. These fees are subject to the provisions of Minnesota Rules, part 4685.2800, 
26.5 	subpart 1, item F; and
26.6 	(2) an annual fee of $21,500, to be paid by June 15 of each calendar year.
26.7 	All fees collected under this paragraph shall be deposited in the state government special 
26.8 	revenue fund.

26.9 	Sec. 20. REVISOR INSTRUCTIONS.
 26.10 	(a) In Minnesota Statutes, chapter 62M, the revisor of statutes shall replace references 
26.11 	to "sections 62M.01 to 62M.16" with "this chapter." In Minnesota Statutes, section 256B.692, 
26.12 	subdivision 2, the revisor of statutes shall replace a reference to "sections 62M.01 to 62M.16" 
26.13 	with "chapter 62M." The revisor shall make any necessary technical and conforming changes 
26.14 	to sentence structure to preserve the meaning of the text.
26.15 	(b) The revisor of statutes shall replace the term "DETERMINATIONS NOT TO 
26.16 	CERTIFY" with "ADVERSE DETERMINATIONS" in the section headnote for Minnesota 
26.17 	Statutes, section 62M.06.

26.18 	EFFECTIVE DATE. Paragraph (a) is effective August 1, 2020. Paragraph (b) is effective 
26.19 	January 1, 2021.

APPENDIX 

Repealed Minnesota Statutes: S3204-2 

62M.02 DEFINITIONS.Subd. 19.Reconsideration request. 
"Reconsideration request" means an initial request by telephone for additional review of a utilization review organization's determination not to certify an admission, extension of stay, or other health care service. 

4685.0100DEFINITIONS. Subp. 9b.Medically necessary care.  
"Medically necessary care" means health care services appropriate, in terms of type, frequency, level, setting, and duration, to the enrollee's diagnosis or condition, and diagnostic testing and preventive services. Medically necessary care must: 

A.
 be consistent with generally accepted practice parameters as determined by health care providers in the same or similar general specialty as typically manages the condition, procedure, or treatment at issue; and 

B.
 help restore or maintain the enrollee's health; or 

C.
 prevent deterioration of the enrollee's condition; or 

D.
 prevent the reasonably likely onset of a health problem or detect an incipient problem.