HF 606

1st Engrossment - 83rd Legislature (2003 - 2004) Posted on 12/15/2009 12:00am

  1.1                          A bill for an act 
  1.2             relating to health; modifying prior authorization 
  1.3             requirements for health care services; establishing 
  1.4             requirements for provider contracting; modifying 
  1.5             provisions for payment of claims; regulating 
  1.6             disclosure of profiling data; amending Minnesota 
  1.7             Statutes 2002, sections 62M.07; 62Q.74; 62Q.75, 
  1.8             subdivision 2; proposing coding for new law in 
  1.9             Minnesota Statutes, chapter 62Q; repealing Minnesota 
  1.10            Statutes 2002, section 62Q.745. 
  1.11  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.12     Section 1.  Minnesota Statutes 2002, section 62M.07, is 
  1.13  amended to read: 
  1.14     62M.07 [PRIOR AUTHORIZATION OF SERVICES.] 
  1.15     (a) Utilization review organizations conducting prior 
  1.16  authorization of services must have written standards that meet 
  1.17  at a minimum the following requirements: 
  1.18     (1) written procedures and criteria used to determine 
  1.19  whether care is appropriate, reasonable, or medically necessary; 
  1.20     (2) a system for providing prompt notification of its 
  1.21  determinations to enrollees and providers and for notifying the 
  1.22  provider, enrollee, or enrollee's designee of appeal procedures 
  1.23  under clause (4); 
  1.24     (3) compliance with section 62M.05, subdivisions 3a and 3b, 
  1.25  regarding time frames for approving and disapproving prior 
  1.26  authorization requests; 
  1.27     (4) written procedures for appeals of denials of prior 
  1.28  authorization which specify the responsibilities of the enrollee 
  2.1   and provider, and which meet the requirements of sections 62M.06 
  2.2   and 72A.285, regarding release of summary review findings; and 
  2.3      (5) procedures to ensure confidentiality of 
  2.4   patient-specific information, consistent with applicable law. 
  2.5      (b) No utilization review organization, health plan 
  2.6   company, or claims administrator may conduct or require prior 
  2.7   authorization of emergency confinement or emergency treatment.  
  2.8   The enrollee or the enrollee's authorized representative may be 
  2.9   required to notify the health plan company, claims 
  2.10  administrator, or utilization review organization as soon after 
  2.11  the beginning of the emergency confinement or emergency 
  2.12  treatment as reasonably possible. 
  2.13     (c) If prior authorization for a health care service is 
  2.14  required, the utilization review organization, health plan 
  2.15  company, or claim administrator must allow providers to submit 
  2.16  requests for prior authorization of such health care services 
  2.17  without unreasonable delay by telephone, facsimile, voice mail, 
  2.18  or through an electronic mechanism 24 hours a day, seven days a 
  2.19  week. 
  2.20     Sec. 2.  [62Q.732] [CITATION.] 
  2.21     Sections 62Q.732 to 62Q.752 may be cited as the "Minnesota 
  2.22  Health Plan Contracting Act." 
  2.23     Sec. 3.  [62Q.733] [DEFINITIONS.] 
  2.24     Subdivision 1.  [APPLICABILITY.] For purposes of sections 
  2.25  62Q.732 to 62Q.752, the following definitions apply.  
  2.26     Subd. 2.  [CONTRACT.] "Contract" means a written agreement 
  2.27  between a health care provider and a health plan company to 
  2.28  provide health care services.  
  2.29     Subd. 3.  [HEALTH CARE PROVIDER OR PROVIDER.] "Health care 
  2.30  provider" or "provider" means a physician, chiropractor, 
  2.31  dentist, or other provider as defined under section 62J.03. 
  2.32     Subd. 4.  [HEALTH PLAN COMPANY.] "Health plan company" 
  2.33  means: 
  2.34     (1) a health maintenance organization operating under 
  2.35  chapter 62D; 
  2.36     (2) a community integrated service network operating under 
  3.1   chapter 62N; 
  3.2      (3) a preferred provider organization as defined in section 
  3.3   145.61, subdivision 4c; or 
  3.4      (4) an insurance company licensed under chapter 60A, 
  3.5   nonprofit health service corporation operating under chapter 
  3.6   62C, fraternal benefit society operating under chapter 64B, or 
  3.7   any other entity that establishes, operates, or maintains a 
  3.8   health benefit plan or network of health care providers where 
  3.9   the providers have entered into a contract with the entity to 
  3.10  provide health care services.  
  3.11     Subd. 5.  [FEE SCHEDULE.] "Fee schedule" means the total 
  3.12  expected financial compensation paid to a health care provider 
  3.13  for providing a health care service as determined by the 
  3.14  contract between the health plan company and the provider, 
  3.15  inclusive of withhold amounts and any amount for which the 
  3.16  patient or other third party may be obligated to pay under the 
  3.17  contract. 
  3.18     Sec. 4.  [62Q.734] [EXEMPTION.] 
  3.19     Sections 62Q.735 to 62Q.739, 62Q.74, and 62Q.752 do not 
  3.20  apply to health plan companies whose annual Minnesota health 
  3.21  premium revenues are less than three percent of the total annual 
  3.22  Minnesota health premium revenues, as measured by the assessment 
  3.23  base of the Minnesota comprehensive health association.  For 
  3.24  purposes of this percentage calculation, a health plan company's 
  3.25  premiums include the Minnesota health premium revenues of its 
  3.26  affiliates. 
  3.27     Sec. 5.  [62Q.735] [PROVIDER CONTRACTING PROCEDURES.] 
  3.28     Subdivision 1.  [CONTRACT DISCLOSURE.] (a) Before requiring 
  3.29  a health care provider to sign a contract, a health plan company 
  3.30  shall give to the provider a complete copy of the proposed 
  3.31  contract, including: 
  3.32     (1) all attachments and exhibits; 
  3.33     (2) operating manuals; 
  3.34     (3) a description of the health plan company's health 
  3.35  service coding standards and requirements for procedures and 
  3.36  diagnoses with modifiers, multiple procedures, and correct 
  4.1   coding edits; and 
  4.2      (4) all guidelines and treatment parameters incorporated or 
  4.3   referenced in the contract. 
  4.4      (b) The health plan company shall make available to the 
  4.5   provider a method or process that allows the provider to 
  4.6   determine the total expected payment amounts for each health 
  4.7   care service to be provided under the contract. 
  4.8      Subd. 2.  [PROPOSED AMENDMENTS.] (a) Any amendment or 
  4.9   change in the terms of an existing contract between a health 
  4.10  plan company and a provider must be disclosed to the provider at 
  4.11  least 90 days prior to the effective date of the proposed 
  4.12  change, with the exception of amendments required of the health 
  4.13  plan company by law or governmental regulatory authority, when 
  4.14  notice shall be given to the provider when the requirement is 
  4.15  made known to the health plan company. 
  4.16     (b) Any amendment or change in the contract that alters the 
  4.17  financial reimbursement or alters the written contractual 
  4.18  policies and procedures governing the relationship between the 
  4.19  provider and the health plan company must be disclosed to the 
  4.20  provider not less than 90 days before the effective date of the 
  4.21  proposed change and the provider must have the opportunity to 
  4.22  terminate the contract before the amendment or change is deemed 
  4.23  to be in effect. 
  4.24     (c) By mutual consent, evidenced in writing in amendments 
  4.25  separate from the base contract and not contingent on 
  4.26  participation, the parties may waive the disclosure requirements 
  4.27  under paragraphs (a) and (b). 
  4.28     Sec. 6.  [62Q.736] [PAYMENT RATES.] 
  4.29     A contract between a health plan company and a provider 
  4.30  shall comply with section 62A.64. 
  4.31     Sec. 7.  [62Q.737] [SERVICE CODE CHANGES.] 
  4.32     (a) For purposes of this section, "service code" means 
  4.33  current procedural terminology (CPT), current dental terminology 
  4.34  (CDT), ICD-CM, diagnosis-related groups (DRGs), or other coding 
  4.35  system. 
  4.36     (b) A health plan company shall not change a service code 
  5.1   properly submitted by a health care provider.  The health plan 
  5.2   company shall determine the manner in which it adjudicates 
  5.3   claims and may limit the service codes it pays for based upon 
  5.4   factors recognized by a service code. 
  5.5      (c) Notwithstanding paragraph (b), a health plan company 
  5.6   may correct an error in a submitted claim that prevents the 
  5.7   claim from being processed, provided that the health plan 
  5.8   company: 
  5.9      (1) notifies the provider of the proposed change and reason 
  5.10  for the proposed change; 
  5.11     (2) offers the provider the opportunity to submit 
  5.12  additional documentation and material to support the submitted 
  5.13  code; and 
  5.14     (3) offers the provider the opportunity to appeal any 
  5.15  changes.  
  5.16     Sec. 8.  [62Q.739] [UNILATERAL TERMS PROHIBITED.] 
  5.17     (a) A contract between a health plan company and a health 
  5.18  care provider shall not contain or require unilateral terms 
  5.19  regarding indemnification or arbitration.  Notwithstanding any 
  5.20  prohibitions in this section, a contract between a health plan 
  5.21  company and a health care provider may be unilaterally 
  5.22  terminated by either party in accordance with the terms of the 
  5.23  contract.  
  5.24     (b) A health plan company may not terminate or fail to 
  5.25  renew a health care provider's contract without cause unless the 
  5.26  company has given the provider a written notice of the 
  5.27  termination or nonrenewal 120 days before the effective date. 
  5.28     Sec. 9.  Minnesota Statutes 2002, section 62Q.74, is 
  5.29  amended to read: 
  5.30     62Q.74 [NETWORK SHADOW CONTRACTING.] 
  5.31     Subdivision 1.  [DEFINITIONS.] (a) For purposes of this 
  5.32  section, the terms defined in this subdivision have the meanings 
  5.33  given. 
  5.34     (b) "category of coverage" means one of the following types 
  5.35  of health-related coverage: 
  5.36     (1) health; 
  6.1      (2) no-fault automobile medical benefits; or 
  6.2      (3) workers' compensation medical benefits. 
  6.3      (c) "Health care provider" or "provider" means an 
  6.4   individual licensed, registered, or regulated by the board of 
  6.5   medical practice under chapter 147, a chiropractor licensed 
  6.6   under sections 148.01 to 148.106, a dentist licensed under 
  6.7   chapter 150A, or a hospital licensed under chapter 144. 
  6.8      (d) "Network organization" means a preferred provider 
  6.9   organization as defined in section 145.61, subdivision 4c; a 
  6.10  managed care organization as defined in section 62Q.01, 
  6.11  subdivision 5; or other entity that uses or consists of a 
  6.12  network of health care providers. 
  6.13     Subd. 2.  [PROVIDER CONSENT REQUIRED.] (a) No network 
  6.14  organization health plan company shall require a health care 
  6.15  provider to participate in a network under a category of 
  6.16  coverage that differs from the category or categories of 
  6.17  coverage to which the existing contract between the network 
  6.18  organization health plan company and the provider applies, 
  6.19  without the affirmative consent of the provider obtained under 
  6.20  subdivision 3.  
  6.21     (b) This section does not apply to situations in which the 
  6.22  network organization wishes No health plan company shall 
  6.23  require, as a condition of participation in any health plan, 
  6.24  product, or other arrangement, the provider to participate in a 
  6.25  new or different health plan, product, or other arrangement 
  6.26  within a category of coverage that is already provided for in an 
  6.27  existing contract between the network organization and the 
  6.28  provider results in a different underlying financial 
  6.29  reimbursement methodology without the affirmative consent of the 
  6.30  provider obtained under subdivision 3.  This paragraph does not 
  6.31  apply to participation in health plan products or other 
  6.32  arrangements that provide health care services to government 
  6.33  programs, including state public programs, Medicare, and 
  6.34  Medicare-related coverage. 
  6.35     (c) Compliance with this section may not be waived in a 
  6.36  contract or otherwise. 
  7.1      Subd. 3.  [CONSENT PROCEDURE.] (a) The network organization 
  7.2   health plan company, if it wishes to apply an existing contract 
  7.3   with a provider to a different category of coverage or health 
  7.4   plan, product, or other arrangement within a category of 
  7.5   coverage that results in a different underlying financial 
  7.6   reimbursement methodology, shall first notify the provider in 
  7.7   writing.  The written notice must include at least the following:
  7.8      (1) the network organization's health plan company's name, 
  7.9   address, and telephone number, and the name of the specific 
  7.10  network, if it differs from that of the network organization; 
  7.11     (2) a description of the proposed new category of 
  7.12  coverage or health plan, product, or other arrangement within a 
  7.13  category of coverage; 
  7.14     (3) the names of all payers expected by the network 
  7.15  organization health plan company to use the network for the new 
  7.16  category of coverage or health plan, product, or other 
  7.17  arrangement within a category of coverage; 
  7.18     (4) the approximate number of current enrollees of the 
  7.19  network organization health plan company in that category of 
  7.20  coverage or health plan, product, or other arrangement within a 
  7.21  category of coverage within the provider's geographical area; 
  7.22     (5) a disclosure of all contract terms of the proposed new 
  7.23  category of coverage or health plan, product, or other 
  7.24  arrangement within a category of coverage, including the 
  7.25  discount or reduced fees, care guidelines, utilization review 
  7.26  criteria, prior notification process, prior authorization 
  7.27  process, and dispute resolution process; 
  7.28     (6) a form for the provider's convenience in accepting or 
  7.29  declining participation in the proposed new category of coverage 
  7.30  or health plan, product, or other arrangement within a category 
  7.31  of coverage, provided that the provider need not use that form 
  7.32  in responding; and 
  7.33     (7) a statement informing the provider of the provisions of 
  7.34  paragraph (b). 
  7.35     (b) Unless the provider has affirmatively agreed to 
  7.36  participate within 60 days after the postmark date of the 
  8.1   notice, the provider is deemed to have not accepted the proposed 
  8.2   new category of coverage or health plan, product, or other 
  8.3   arrangement within a category of coverage. 
  8.4      Subd. 4.  [CONTRACT TERMINATION RESTRICTED.] A network 
  8.5   organization health plan company must not terminate an existing 
  8.6   contract with a provider, or fail to honor the contract in good 
  8.7   faith, based solely on the provider's decision not to accept a 
  8.8   proposed new category of coverage or health plan, product, or 
  8.9   other arrangement within a category of coverage.  The most 
  8.10  recent agreed-upon contractual obligations remain in force until 
  8.11  the existing contract's renewal or termination date. 
  8.12     Subd. 5.  [REMEDY.] If a network organization health plan 
  8.13  company violates this section by reimbursing a provider as if 
  8.14  the provider had agreed under this section to participate in the 
  8.15  network under a category of coverage or health plan, product, or 
  8.16  other arrangement within a category of coverage that results in 
  8.17  a different underlying financial reimbursement methodology to 
  8.18  which the provider has not agreed, the provider has a cause of 
  8.19  action against the network organization health plan company to 
  8.20  recover two times the difference between the reasonable charges 
  8.21  for claims affected by the violation and the amounts actually 
  8.22  paid to the provider.  The provider is also entitled to recover 
  8.23  costs, disbursements, and reasonable attorney fees. 
  8.24     Sec. 10.  Minnesota Statutes 2002, section 62Q.75, 
  8.25  subdivision 2, is amended to read: 
  8.26     Subd. 2.  [CLAIMS PAYMENTS.] (a) This section applies to 
  8.27  clean claims submitted to a health plan company or third-party 
  8.28  administrator for services provided by any: 
  8.29     (1) health care provider, except a provider licensed under 
  8.30  chapter 151; 
  8.31     (2) home health care provider, as defined in section 
  8.32  144A.43, subdivision 4; or 
  8.33     (3) health care facility. 
  8.34  All health plan companies and third-party administrators must 
  8.35  pay or deny claims that are clean claims within 30 calendar days 
  8.36  after the date upon which the health plan company or third-party 
  9.1   administrator received the claim. 
  9.2      (b) If a health plan company or third-party administrator 
  9.3   determines that a claim is not clean, the health plan company or 
  9.4   third-party administrator must make available to and notify the 
  9.5   health care provider of the reasons for this determination 
  9.6   within 30 calendar days after the date upon which the health 
  9.7   plan company or third-party administrator received the claim.  
  9.8   Where evidence of suspected fraud is present, the requirement to 
  9.9   disclose the reasons for the determination that a claim is not 
  9.10  clean need not be specific. 
  9.11     (c) If a health plan company or third-party administrator 
  9.12  does not pay or deny a clean claim within the period provided in 
  9.13  paragraph (a), the health plan company or third-party 
  9.14  administrator must pay interest on the claim for the period 
  9.15  beginning on the day after the required payment date specified 
  9.16  in paragraph (a) and ending on the date on which the health plan 
  9.17  company or third-party administrator makes the payment or denies 
  9.18  the claim.  In any payment, the health plan company or 
  9.19  third-party administrator must itemize any interest payment 
  9.20  being made separately from other payments being made for 
  9.21  services provided.  The health plan company or third-party 
  9.22  administrator may, at its discretion, require the health care 
  9.23  provider to bill the health plan company or third-party 
  9.24  administrator for the interest required under this section 
  9.25  before any interest payment is made. Interest payments must be 
  9.26  made to the health care provider no less frequently than 
  9.27  quarterly. 
  9.28     (c) (d) The rate of interest paid by a health plan company 
  9.29  or third-party administrator under this subdivision shall be 1.5 
  9.30  percent per month or any part of a month. 
  9.31     (d) (e) A health plan company or third-party administrator 
  9.32  is not required to make an interest payment on a claim for which 
  9.33  payment has been delayed for purposes of reviewing potentially 
  9.34  fraudulent or abusive billing practices. 
  9.35     (e) The commissioner may not assess a financial 
  9.36  administrative penalty against a health plan company for 
 10.1   violation of this subdivision. 
 10.2      (f) The commissioner may assess a financial administrative 
 10.3   penalty against a health plan company for violation of this 
 10.4   subdivision when there is a pattern of abuse that demonstrates a 
 10.5   lack of good faith effort and a systematic failure of the health 
 10.6   plan company to comply with this subdivision. 
 10.7      Sec. 11.  [62Q.752] [DISCLOSURE OF PROFILING DATA.] 
 10.8      Subdivision 1.  [DISCLOSURE.] Before releasing provider 
 10.9   identifiable profiling data to consumers or health plan members, 
 10.10  health plan companies shall provide a provider with an 
 10.11  opportunity to review the provider's identifiable data and a 
 10.12  summary describing the underlying analysis and methodology.  A 
 10.13  provider shall be given 90 days after receipt of the 
 10.14  identifiable data and summary to comment.  
 10.15     Subd. 2.  [RELEASE OF DATA; APPEAL.] Before a health plan 
 10.16  company or health plan sponsor may release any data covered by 
 10.17  this section, the health plan company or plan sponsor must 
 10.18  provide the subject of the data the opportunity to provide the 
 10.19  health plan company or plan sponsor with information supporting 
 10.20  or critical to the methodology procedure or information utilized 
 10.21  in assembling the data to be released.  The health plan company 
 10.22  or plan sponsor must consider any information provided by the 
 10.23  data subject and provide a written response to the data subject 
 10.24  before releasing the data.  A health plan company or plan 
 10.25  sponsor must provide the subject of the data with a timely 
 10.26  appeal process if the subject of the data, after receiving the 
 10.27  health plan company or plan sponsor's written response, 
 10.28  continues to contest the methodology, procedure, or information 
 10.29  utilized by the health plan company or plan sponsor. 
 10.30     Sec. 12.  [REPEALER.] 
 10.31     Minnesota Statutes 2002, section 62Q.745, is repealed. 
 10.32     Sec. 13.  [EFFECTIVE DATE.] 
 10.33     Sections 1 to 12 are effective July 1, 2003.