HF 3334

Introduction - 94th Legislature (2025 - 2026)

Posted on 05/17/2025 12:38 p.m.

A bill for an act
relating to health; modifying standards for utilization review performance; creating
a cause of action for wrongful denials of prior authorizations by utilization review
organizations or their reviewing physicians; providing for attorney general
enforcement; amending Minnesota Statutes 2024, section 62M.04, subdivision 4;
proposing coding for new law in Minnesota Statutes, chapter 62M.

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

Section 1.

Minnesota Statutes 2024, section 62M.04, subdivision 4, is amended to read:

Subd. 4.

Additional information.

new text begin (a) new text end 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 authorization 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
authorized;

(2) referred the case to a physician for review; and

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

new text begin (b) Prior to issuing an adverse determination, the reviewing physician for the utilization
review organization under paragraph (a) must contact the attending health care professional
to obtain more details on the medical necessity of the service.
new text end

new text begin (c) new text end Nothing in this chapter 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.

new text begin [62M.112] CAUSE OF ACTION; ATTORNEY GENERAL ENFORCEMENT.
new text end

new text begin Subdivision 1. new text end

new text begin Cause of action. new text end

new text begin (a) An enrollee injured by a denial of a prior authorization
by a utilization review organization for a health care service has a cause of action against
a utilization review organization if the following occurs:
new text end

new text begin (1) the utilization review organization has made an adverse determination of both a
request for prior authorization and a subsequent appeal by the enrollee's attending health
care professional;
new text end

new text begin (2) the adverse determination deviates from accepted norms of practice in the medical
community;
new text end

new text begin (3) the adverse determination deviates from the recommendation of the enrollee's
attending health care professional; and
new text end

new text begin (4) the adverse determination causes injury to the enrollee.
new text end

new text begin (b) An enrollee injured by a denial of a prior authorization by a utilization review
organization for a health care service may bring an action for medical malpractice against
the physician who reviewed the request for prior authorization on behalf of a utilization
review organization and recommended denial of the request under section 62M.04,
subdivision 4, or 62M.06.
new text end

new text begin (c) A utilization review organization or a reviewing physician for a utilization review
organization may only be found liable under this section if documentation is provided that
shows the utilization review organization or reviewing physician disregarded the judgment
of the enrollee's attending health care professional and relevant information supporting the
initial request for prior authorization or appeal of the adverse determination, or both.
new text end

new text begin (d) An enrollee may file a complaint to the commissioner responsible for regulating the
utilization review organization under section 62M.11 prior to bringing an action, concurrently
with a pending action, or after bringing an action under this section.
new text end

new text begin (e) This section does not create a cause of action against an attending health care
professional of an enrollee whose prior authorization was denied. An attending health care
professional is immune from civil liability created under this subdivision.
new text end

new text begin Subd. 2. new text end

new text begin Attorney general enforcement. new text end

new text begin The attorney general may investigate and
bring an action against a utilization review organization to enforce this section under section
8.31.
new text end