SF 3712
Introduction - 94th Legislature (2025 - 2026)
Posted on 02/24/2026 09:32 a.m.
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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; providing for attorney general enforcement; authorizing fines by
the commissioner of commerce; requiring oversight of utilization review by
health-related licensing boards; amending Minnesota Statutes 2024, sections
62M.04, subdivision 4; 62M.05, subdivision 3a; 62M.06, by adding a subdivision;
62M.07, subdivision 3; proposing coding for new law in Minnesota Statutes,
chapters 62M; 214.
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 todeleted 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.
Minnesota Statutes 2024, section 62M.05, subdivision 3a, is amended to read:
Subd. 3a.
Standard review determination.
(a) A standard review determination on all
requests for utilization review must be communicated to the provider and enrollee in
accordance with this subdivision within five business days after receiving the request,
regardless of how the request was received, provided that all information reasonably
necessary to make a determination on the request has been made available to the utilization
review organization.
(b) When a determination is made to authorize, 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 authorized; and the date of the service, procedure, or
admission. If the utilization review organization indicates authorization by use of a number,
the number must be called the "authorization 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 adverse determination is made,new text begin writtennew text end notification must be provided within
the time periods specified in paragraph (a) deleted text begin by telephone,deleted text end by facsimile to a verified numberdeleted text begin ,deleted text end
or by electronic mail to a secure electronic mailbox to the attending health care professional
and hospital or physician office as applicable. deleted text begin Written notification must also be sent to the
hospital or physician office 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.deleted text end new text begin
Notification must also be made by telephone to the attending health care professional through
a call made by the physician or appropriate specialist that made the adverse determination
under section 62M.09.new text end 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 all reasons relied on by the utilization review
organization 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 an adverse determination may include, among other
things, the lack of adequate information to authorize after a reasonable attempt has been
made to contact the provider or enrollee.
(d) When an adverse determination is made, 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 2024, section 62M.06, is amended by adding a subdivision to
read:
new text begin Subd. 5. new text end
new text begin Fines. new text end
new text begin
(a) The commissioner of commerce must impose a fine on a utilization
review organization if the rate at which adverse determinations are reversed exceeds 40
percent in any period of 12 consecutive months for any of the following:
new text end
new text begin
(1) expedited appeals under subdivision 2;
new text end
new text begin
(2) standard appeals under subdivision 3; or
new text end
new text begin
(3) external reviews under section 62Q.73.
new text end
new text begin
(b) The fine under paragraph (a) must not exceed $........
new text end
Sec. 4.
Minnesota Statutes 2024, section 62M.07, subdivision 3, is amended to read:
Subd. 3.
Retrospective revocation or limitation of prior authorization.
No utilization
review organization, health plan company, or claims administrator may revoke, limit,
condition, or restrict a prior authorization that has been authorized unless there is evidence
that the prior authorization was authorized based on fraud or misinformation or a previously
approved prior authorization conflicts with state or federal law. Application of a deductible,
coinsurance, or other cost-sharing requirement deleted text begin does not constitutedeleted text end new text begin constitutesnew text end a limit,
condition, or restriction under this subdivision.
Sec. 5.
new text begin
[62M.112] CAUSE OF ACTION.
new text end
new text begin Subdivision 1. new text end
new text begin Cause of action; documentation. 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 makes 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) A utilization review organization may only be found liable under this section if
documentation is provided that shows the utilization review organization 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
(c) A court may award to a prevailing plaintiff from a person found liable under this
section the following:
new text end
new text begin
(1) general and special damages, including damages for mental anguish;
new text end
new text begin
(2) punitive damages;
new text end
new text begin
(3) injunctive relief and any other equitable relief the court deems appropriate; and
new text end
new text begin
(4) costs, disbursements, and reasonable attorney fees.
new text end
new text begin Subd. 2. new text end
new text begin Administrative complaint. new text end
new text begin
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 Subd. 3. new text end
new text begin Immunity. new text end
new text begin
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 EFFECTIVE DATE. new text end
new text begin
This section is effective August 1, 2026, and applies to causes
of action accruing on or after that date.
new text end
Sec. 6.
new text begin
[62M.20] ATTORNEY GENERAL ENFORCEMENT.
new text end
new text begin
The attorney general has the authority under section 8.31 to enforce this chapter.
new text end
Sec. 7.
new text begin
[214.125] UTILIZATION REVIEW OVERSIGHT.
new text end
new text begin
Health-related licensing boards must apply and enforce the standards of professional
conduct to the performance of utilization review, as defined in section 62M.02, by the
boards' licensees.
new text end