SF 1219

5th Engrossment - 81st Legislature (1999 - 2000) Posted on 12/15/2009 12:00am

  1.1                          A bill for an act 
  1.2             relating to health; establishing a uniform complaint 
  1.3             resolution process for health plan companies; 
  1.4             establishing an external review process; amending 
  1.5             Minnesota Statutes 1998, sections 62D.11, subdivision 
  1.6             1; 62M.01; 62M.02, subdivisions 3, 4, 5, 6, 7, 9, 10, 
  1.7             11, 12, 17, 20, 21, and by adding a subdivision; 
  1.8             62M.03, subdivisions 1 and 3; 62M.04, subdivisions 1, 
  1.9             2, 3, and 4; 62M.05; 62M.06; 62M.07; 62M.09, 
  1.10            subdivision 3; 62M.10, subdivisions 2, 5, and 7; 
  1.11            62M.12; 62M.15; 62Q.106; 62Q.19, subdivision 5a; 
  1.12            62T.04; 72A.201, subdivision 4a; and 256B.692, 
  1.13            subdivision 2; proposing coding for new law in 
  1.14            Minnesota Statutes, chapters 62D; and 62Q; repealing 
  1.15            Minnesota Statutes 1998, sections 62D.11, subdivisions 
  1.16            1b and 2; 62Q.105; 62Q.11; and 62Q.30; Minnesota 
  1.17            Rules, parts 4685.0100, subparts 4 and 4a; 4685.1010, 
  1.18            subpart 3; and 4685.1700. 
  1.19  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.20     Section 1.  Minnesota Statutes 1998, section 62D.11, 
  1.21  subdivision 1, is amended to read: 
  1.22     Subdivision 1.  [ENROLLEE COMPLAINT SYSTEM.] Every health 
  1.23  maintenance organization shall establish and maintain a 
  1.24  complaint system, as required under section 62Q.105 sections 
  1.25  62Q.68 to 62Q.72 to provide reasonable procedures for the 
  1.26  resolution of written complaints initiated by or on behalf of 
  1.27  enrollees concerning the provision of health care 
  1.28  services.  "Provision of health services" includes, but is not 
  1.29  limited to, questions of the scope of coverage, quality of care, 
  1.30  and administrative operations.  The health maintenance 
  1.31  organization must inform enrollees that they may choose to use 
  1.32  arbitration to appeal a health maintenance organization's 
  2.1   internal appeal decision.  The health maintenance organization 
  2.2   must also inform enrollees that they have the right to use 
  2.3   arbitration to appeal a health maintenance organization's 
  2.4   internal appeal decision not to certify an admission, procedure, 
  2.5   service, or extension of stay under section 62M.06.  If an 
  2.6   enrollee chooses to use arbitration, the health maintenance 
  2.7   organization must participate. 
  2.8      Sec. 2.  [62D.124] [GEOGRAPHIC ACCESSIBILITY.] 
  2.9      Subdivision 1.  [PRIMARY CARE; MENTAL HEALTH SERVICES; 
  2.10  GENERAL HOSPITAL SERVICES.] Within the health maintenance 
  2.11  organization's service area, the maximum travel distance or time 
  2.12  shall be the lesser of 30 miles or 30 minutes to the nearest 
  2.13  provider of each of the following services:  primary care 
  2.14  services, mental health services, and general hospital 
  2.15  services.  The health maintenance organization must designate 
  2.16  which method is used.  
  2.17     Subd. 2.  [OTHER HEALTH SERVICES.] Within a health 
  2.18  maintenance organization's service area, the maximum travel 
  2.19  distance or time shall be the lesser of 60 miles or 60 minutes 
  2.20  to the nearest provider of specialty physician services, 
  2.21  ancillary services, specialized hospital services, and all other 
  2.22  health services not listed in subdivision 1.  The health 
  2.23  maintenance organization must designate which method is used. 
  2.24     Subd. 3.  [EXCEPTION.] The commissioner shall grant an 
  2.25  exception to the requirements of this section according to 
  2.26  Minnesota Rules, part 4685.1010, subpart 4, if the health 
  2.27  maintenance organization can demonstrate with specific data that 
  2.28  the requirement of subdivision 1 or 2 is not feasible in a 
  2.29  particular service area or part of a service area. 
  2.30     Subd. 4.  [APPLICATION.] (a) Subdivisions 1 and 2 do not 
  2.31  apply if an enrollee is referred to a referral center for health 
  2.32  care services.  
  2.33     (b) Subdivision 1 does not apply: 
  2.34     (1) if an enrollee has chosen a health plan with full 
  2.35  knowledge that the health plan has no participating providers 
  2.36  within 30 miles or 30 minutes of the enrollee's place of 
  3.1   residence; or 
  3.2      (2) to service areas approved before May 24, 1993. 
  3.3      Sec. 3.  Minnesota Statutes 1998, section 62M.01, is 
  3.4   amended to read: 
  3.5      62M.01 [CITATION, JURISDICTION, AND SCOPE.] 
  3.6      Subdivision 1.  [POPULAR NAME.] Sections 62M.01 to 62M.16 
  3.7   may be cited as the "Minnesota Utilization Review Act of 1992." 
  3.8      Subd. 2.  [JURISDICTION.] Sections 62M.01 to 62M.16 apply 
  3.9   to any insurance company licensed under chapter 60A to offer, 
  3.10  sell, or issue a policy of accident and sickness insurance as 
  3.11  defined in section 62A.01; a health service plan licensed under 
  3.12  chapter 62C; a health maintenance organization licensed under 
  3.13  chapter 62D; a community integrated service network licensed 
  3.14  under chapter 62N; an accountable provider network operating 
  3.15  under chapter 62T; a fraternal benefit society operating under 
  3.16  chapter 64B; a joint self-insurance employee health plan 
  3.17  operating under chapter 62H; a multiple employer welfare 
  3.18  arrangement, as defined in section 3 of the Employee Retirement 
  3.19  Income Security Act of 1974 (ERISA), United States Code, title 
  3.20  29, section 1103, as amended; a third party administrator 
  3.21  licensed under section 60A.23, subdivision 8, that provides 
  3.22  utilization review services for the administration of benefits 
  3.23  under a health benefit plan as defined in section 62M.02; or any 
  3.24  entity performing utilization review on behalf of a business 
  3.25  entity in this state pursuant to a health benefit plan covering 
  3.26  a Minnesota resident. 
  3.27     Subd. 3.  [SCOPE.] Sections 62M.02, 62M.07, and 62M.09, 
  3.28  subdivision 4, apply to prior authorization of services.  
  3.29  Nothing in sections 62M.01 to 62M.16 applies to review of claims 
  3.30  after submission to determine eligibility for benefits under a 
  3.31  health benefit plan.  The appeal procedure described in section 
  3.32  62M.06 applies to any complaint as defined under section 62Q.68, 
  3.33  subdivision 2, that requires a medical determination in its 
  3.34  resolution.  
  3.35     Sec. 4.  Minnesota Statutes 1998, section 62M.02, 
  3.36  subdivision 3, is amended to read: 
  4.1      Subd. 3.  [ATTENDING DENTIST.] "Attending dentist" means 
  4.2   the dentist with primary responsibility for the dental care 
  4.3   provided to a patient an enrollee. 
  4.4      Sec. 5.  Minnesota Statutes 1998, section 62M.02, 
  4.5   subdivision 4, is amended to read: 
  4.6      Subd. 4.  [ATTENDING PHYSICIAN HEALTH CARE PROFESSIONAL.] 
  4.7   "Attending physician health care professional" means 
  4.8   the physician health care professional providing care within the 
  4.9   scope of their practice and with primary responsibility for the 
  4.10  care provided to a patient in a hospital or other health care 
  4.11  facility an enrollee.  Attending health care professional shall 
  4.12  include only physicians; chiropractors; dentists; mental health 
  4.13  professionals as defined in section 245.462, subdivision 18, or 
  4.14  section 245.4871, subdivision 27; podiatrists; and advanced 
  4.15  practice nurses. 
  4.16     Sec. 6.  Minnesota Statutes 1998, section 62M.02, 
  4.17  subdivision 5, is amended to read: 
  4.18     Subd. 5.  [CERTIFICATION.] "Certification" means a 
  4.19  determination by a utilization review organization that an 
  4.20  admission, extension of stay, or other health care service has 
  4.21  been reviewed and that it, based on the information provided, 
  4.22  meets the utilization review requirements of the applicable 
  4.23  health plan and the health carrier plan company will then pay 
  4.24  for the covered benefit, provided the preexisting limitation 
  4.25  provisions, the general exclusion provisions, and any 
  4.26  deductible, copayment, coinsurance, or other policy requirements 
  4.27  have been met. 
  4.28     Sec. 7.  Minnesota Statutes 1998, section 62M.02, 
  4.29  subdivision 6, is amended to read: 
  4.30     Subd. 6.  [CLAIMS ADMINISTRATOR.] "Claims administrator" 
  4.31  means an entity that reviews and determines whether to pay 
  4.32  claims to enrollees, physicians, hospitals, or others or 
  4.33  providers based on the contract provisions of the health plan 
  4.34  contract.  Claims administrators may include insurance companies 
  4.35  licensed under chapter 60A to offer, sell, or issue a policy of 
  4.36  accident and sickness insurance as defined in section 62A.01; a 
  5.1   health service plan licensed under chapter 62C; a health 
  5.2   maintenance organization licensed under chapter 62D; a community 
  5.3   integrated service network licensed under chapter 62N; an 
  5.4   accountable provider network operating under chapter 62T; a 
  5.5   fraternal benefit society operating under chapter 64B; a 
  5.6   multiple employer welfare arrangement, as defined in section 3 
  5.7   of the Employee Retirement Income Security Act of 1974 (ERISA), 
  5.8   United States Code, title 29, section 1103, as amended. 
  5.9      Sec. 8.  Minnesota Statutes 1998, section 62M.02, 
  5.10  subdivision 7, is amended to read: 
  5.11     Subd. 7.  [CLAIMANT.] "Claimant" means the enrollee or 
  5.12  covered person who files a claim for benefits or a provider of 
  5.13  services who, pursuant to a contract with a claims 
  5.14  administrator, files a claim on behalf of an enrollee or covered 
  5.15  person. 
  5.16     Sec. 9.  Minnesota Statutes 1998, section 62M.02, 
  5.17  subdivision 9, is amended to read: 
  5.18     Subd. 9.  [CONCURRENT REVIEW.] "Concurrent review" means 
  5.19  utilization review conducted during a patient's an enrollee's 
  5.20  hospital stay or course of treatment and has the same meaning as 
  5.21  continued stay review. 
  5.22     Sec. 10.  Minnesota Statutes 1998, section 62M.02, 
  5.23  subdivision 10, is amended to read: 
  5.24     Subd. 10.  [DISCHARGE PLANNING.] "Discharge planning" means 
  5.25  the process that assesses a patient's an enrollee's need for 
  5.26  treatment after hospitalization in order to help arrange for the 
  5.27  necessary services and resources to effect an appropriate and 
  5.28  timely discharge. 
  5.29     Sec. 11.  Minnesota Statutes 1998, section 62M.02, 
  5.30  subdivision 11, is amended to read: 
  5.31     Subd. 11.  [ENROLLEE.] "Enrollee" means an individual who 
  5.32  has elected to contract for, or participate in, a health benefit 
  5.33  plan for enrollee coverage or for dependent coverage covered by 
  5.34  a health benefit plan and includes an insured policyholder, 
  5.35  subscriber, contract holder, member, covered person, or 
  5.36  certificate holder. 
  6.1      Sec. 12.  Minnesota Statutes 1998, section 62M.02, 
  6.2   subdivision 12, is amended to read: 
  6.3      Subd. 12.  [HEALTH BENEFIT PLAN.] "Health benefit plan" 
  6.4   means a policy, contract, or certificate issued by a health 
  6.5   carrier to an employer or individual plan company for the 
  6.6   coverage of medical, dental, or hospital benefits.  A health 
  6.7   benefit plan does not include coverage that is: 
  6.8      (1) limited to disability or income protection coverage; 
  6.9      (2) automobile medical payment coverage; 
  6.10     (3) supplemental to liability insurance; 
  6.11     (4) designed solely to provide payments on a per diem, 
  6.12  fixed indemnity, or nonexpense incurred basis; 
  6.13     (5) credit accident and health insurance issued under 
  6.14  chapter 62B; 
  6.15     (6) blanket accident and sickness insurance as defined in 
  6.16  section 62A.11; 
  6.17     (7) accident only coverage issued by a licensed and tested 
  6.18  insurance agent; or 
  6.19     (8) workers' compensation. 
  6.20     Sec. 13.  Minnesota Statutes 1998, section 62M.02, is 
  6.21  amended by adding a subdivision to read: 
  6.22     Subd. 12a.  [HEALTH PLAN COMPANY.] "Health plan company" 
  6.23  means a health plan company as defined in section 62Q.01, 
  6.24  subdivision 4, and includes an accountable provider network 
  6.25  operating under chapter 62T. 
  6.26     Sec. 14.  Minnesota Statutes 1998, section 62M.02, 
  6.27  subdivision 17, is amended to read: 
  6.28     Subd. 17.  [PROVIDER.] "Provider" means a licensed health 
  6.29  care facility, physician, or other health care professional that 
  6.30  delivers health care services to an enrollee or covered person. 
  6.31     Sec. 15.  Minnesota Statutes 1998, section 62M.02, 
  6.32  subdivision 20, is amended to read: 
  6.33     Subd. 20.  [UTILIZATION REVIEW.] "Utilization review" means 
  6.34  the evaluation of the necessity, appropriateness, and efficacy 
  6.35  of the use of health care services, procedures, and facilities, 
  6.36  by a person or entity other than the attending physician health 
  7.1   care professional, for the purpose of determining the medical 
  7.2   necessity of the service or admission.  Utilization review also 
  7.3   includes review conducted after the admission of the enrollee.  
  7.4   It includes situations where the enrollee is unconscious or 
  7.5   otherwise unable to provide advance notification.  Utilization 
  7.6   review does not include the imposition of a requirement that 
  7.7   services be received by or upon referral from a participating 
  7.8   provider a referral or participation in a referral process by a 
  7.9   participating provider unless the provider is acting as a 
  7.10  utilization review organization. 
  7.11     Sec. 16.  Minnesota Statutes 1998, section 62M.02, 
  7.12  subdivision 21, is amended to read: 
  7.13     Subd. 21.  [UTILIZATION REVIEW ORGANIZATION.] "Utilization 
  7.14  review organization" means an entity including but not limited 
  7.15  to an insurance company licensed under chapter 60A to offer, 
  7.16  sell, or issue a policy of accident and sickness insurance as 
  7.17  defined in section 62A.01; a health service plan licensed under 
  7.18  chapter 62C; a health maintenance organization licensed under 
  7.19  chapter 62D; a community integrated service network licensed 
  7.20  under chapter 62N; an accountable provider network operating 
  7.21  under chapter 62T; a fraternal benefit society operating under 
  7.22  chapter 64B; a joint self-insurance employee health plan 
  7.23  operating under chapter 62H; a multiple employer welfare 
  7.24  arrangement, as defined in section 3 of the Employee Retirement 
  7.25  Income Security Act of 1974 (ERISA), United States Code, title 
  7.26  29, section 1103, as amended; a third party administrator 
  7.27  licensed under section 60A.23, subdivision 8, which conducts 
  7.28  utilization review and determines certification of an admission, 
  7.29  extension of stay, or other health care services for a Minnesota 
  7.30  resident; or any entity performing utilization review that is 
  7.31  affiliated with, under contract with, or conducting utilization 
  7.32  review on behalf of, a business entity in this state. 
  7.33     Sec. 17.  Minnesota Statutes 1998, section 62M.03, 
  7.34  subdivision 1, is amended to read: 
  7.35     Subdivision 1.  [LICENSED UTILIZATION REVIEW ORGANIZATION.] 
  7.36  Beginning January 1, 1993, any organization that meets the 
  8.1   definition of utilization review organization in section 62M.02, 
  8.2   subdivision 21, must be licensed under chapter 60A, 62C, 62D, 
  8.3   62N, 62T, or 64B, or registered under this chapter and must 
  8.4   comply with sections 62M.01 to 62M.16 and section 72A.201, 
  8.5   subdivisions 8 and 8a.  Each licensed community integrated 
  8.6   service network or health maintenance organization that has an 
  8.7   employed staff model of providing health care services shall 
  8.8   comply with sections 62M.01 to 62M.16 and section 72A.201, 
  8.9   subdivisions 8 and 8a, for any services provided by providers 
  8.10  under contract. 
  8.11     Sec. 18.  Minnesota Statutes 1998, section 62M.03, 
  8.12  subdivision 3, is amended to read: 
  8.13     Subd. 3.  [PENALTIES AND ENFORCEMENTS.] If a utilization 
  8.14  review organization fails to comply with sections 62M.01 to 
  8.15  62M.16, the organization may not provide utilization review 
  8.16  services for any Minnesota resident.  The commissioner of 
  8.17  commerce may issue a cease and desist order under section 
  8.18  45.027, subdivision 5, to enforce this provision.  The cease and 
  8.19  desist order is subject to appeal under chapter 14.  A 
  8.20  nonlicensed utilization review organization that fails to comply 
  8.21  with the provisions of sections 62M.01 to 62M.16 is subject to 
  8.22  all applicable penalty and enforcement provisions of section 
  8.23  72A.201.  Each utilization review organization licensed under 
  8.24  chapter 60A, 62C, 62D, 62N, 62T, or 64B shall comply with 
  8.25  sections 62M.01 to 62M.16 as a condition of licensure. 
  8.26     Sec. 19.  Minnesota Statutes 1998, section 62M.04, 
  8.27  subdivision 1, is amended to read: 
  8.28     Subdivision 1.  [RESPONSIBILITY FOR OBTAINING 
  8.29  CERTIFICATION.] A health benefit plan that includes utilization 
  8.30  review requirements must specify the process for notifying the 
  8.31  utilization review organization in a timely manner and obtaining 
  8.32  certification for health care services.  Each health plan 
  8.33  company must provide a clear and concise description of this 
  8.34  process to an enrollee as part of the policy, subscriber 
  8.35  contract, or certificate of coverage.  In addition to the 
  8.36  enrollee, the utilization review organization must allow any 
  9.1   licensed hospital, physician or the physician's provider or 
  9.2   provider's designee, or responsible patient representative, 
  9.3   including a family member, to fulfill the obligations under the 
  9.4   health plan. 
  9.5      A claims administrator that contracts directly with 
  9.6   providers for the provision of health care services to enrollees 
  9.7   may, through contract, require the provider to notify the review 
  9.8   organization in a timely manner and obtain certification for 
  9.9   health care services. 
  9.10     Sec. 20.  Minnesota Statutes 1998, section 62M.04, 
  9.11  subdivision 2, is amended to read: 
  9.12     Subd. 2.  [INFORMATION UPON WHICH UTILIZATION REVIEW IS 
  9.13  CONDUCTED.] If the utilization review organization is conducting 
  9.14  routine prospective and concurrent utilization review, 
  9.15  utilization review organizations must collect only the 
  9.16  information necessary to certify the admission, procedure of 
  9.17  treatment, and length of stay. 
  9.18     (a) Utilization review organizations may request, but may 
  9.19  not require, hospitals, physicians, or other providers to supply 
  9.20  numerically encoded diagnoses or procedures as part of the 
  9.21  certification process. 
  9.22     (b) Utilization review organizations must not routinely 
  9.23  request copies of medical records for all patients reviewed.  In 
  9.24  performing prospective and concurrent review, copies of the 
  9.25  pertinent portion of the medical record should be required only 
  9.26  when a difficulty develops in certifying the medical necessity 
  9.27  or appropriateness of the admission or extension of stay. 
  9.28     (c) Utilization review organizations may request copies of 
  9.29  medical records retrospectively for a number of purposes, 
  9.30  including auditing the services provided, quality assurance 
  9.31  review, ensuring compliance with the terms of either the health 
  9.32  benefit plan or the provider contract, and compliance with 
  9.33  utilization review activities.  Except for reviewing medical 
  9.34  records associated with an appeal or with an investigation or 
  9.35  audit of data discrepancies, health care providers must be 
  9.36  reimbursed for the reasonable costs of duplicating records 
 10.1   requested by the utilization review organization for 
 10.2   retrospective review unless otherwise provided under the terms 
 10.3   of the provider contract. 
 10.4      Sec. 21.  Minnesota Statutes 1998, section 62M.04, 
 10.5   subdivision 3, is amended to read: 
 10.6      Subd. 3.  [DATA ELEMENTS.] Except as otherwise provided in 
 10.7   sections 62M.01 to 62M.16, for purposes of certification a 
 10.8   utilization review organization must limit its data requirements 
 10.9   to the following elements: 
 10.10     (a) Patient information that includes the following: 
 10.11     (1) name; 
 10.12     (2) address; 
 10.13     (3) date of birth; 
 10.14     (4) sex; 
 10.15     (5) social security number or patient identification 
 10.16  number; 
 10.17     (6) name of health carrier plan company or health plan; and 
 10.18     (7) plan identification number. 
 10.19     (b) Enrollee information that includes the following: 
 10.20     (1) name; 
 10.21     (2) address; 
 10.22     (3) social security number or employee identification 
 10.23  number; 
 10.24     (4) relation to patient; 
 10.25     (5) employer; 
 10.26     (6) health benefit plan; 
 10.27     (7) group number or plan identification number; and 
 10.28     (8) availability of other coverage. 
 10.29     (c) Attending physician or provider health care 
 10.30  professional information that includes the following: 
 10.31     (1) name; 
 10.32     (2) address; 
 10.33     (3) telephone numbers; 
 10.34     (4) degree and license; 
 10.35     (5) specialty or board certification status; and 
 10.36     (6) tax identification number or other identification 
 11.1   number. 
 11.2      (d) Diagnosis and treatment information that includes the 
 11.3   following: 
 11.4      (1) primary diagnosis with associated ICD or DSM coding, if 
 11.5   available; 
 11.6      (2) secondary diagnosis with associated ICD or DSM coding, 
 11.7   if available; 
 11.8      (3) tertiary diagnoses with associated ICD or DSM coding, 
 11.9   if available; 
 11.10     (4) proposed procedures or treatments with ICD or 
 11.11  associated CPT codes, if available; 
 11.12     (5) surgical assistant requirement; 
 11.13     (6) anesthesia requirement; 
 11.14     (7) proposed admission or service dates; 
 11.15     (8) proposed procedure date; and 
 11.16     (9) proposed length of stay. 
 11.17     (e) Clinical information that includes the following: 
 11.18     (1) support and documentation of appropriateness and level 
 11.19  of service proposed; and 
 11.20     (2) identification of contact person for detailed clinical 
 11.21  information. 
 11.22     (f) Facility information that includes the following:  
 11.23     (1) type; 
 11.24     (2) licensure and certification status and DRG exempt 
 11.25  status; 
 11.26     (3) name; 
 11.27     (4) address; 
 11.28     (5) telephone number; and 
 11.29     (6) tax identification number or other identification 
 11.30  number. 
 11.31     (g) Concurrent or continued stay review information that 
 11.32  includes the following: 
 11.33     (1) additional days, services, or procedures proposed; 
 11.34     (2) reasons for extension, including clinical information 
 11.35  sufficient for support of appropriateness and level of service 
 11.36  proposed; and 
 12.1      (3) diagnosis status. 
 12.2      (h) For admissions to facilities other than acute medical 
 12.3   or surgical hospitals, additional information that includes the 
 12.4   following: 
 12.5      (1) history of present illness; 
 12.6      (2) patient treatment plan and goals; 
 12.7      (3) prognosis; 
 12.8      (4) staff qualifications; and 
 12.9      (5) 24-hour availability of staff. 
 12.10     Additional information may be required for other specific 
 12.11  review functions such as discharge planning or catastrophic case 
 12.12  management.  Second opinion information may also be required, 
 12.13  when applicable, to support benefit plan requirements. 
 12.14     Sec. 22.  Minnesota Statutes 1998, section 62M.04, 
 12.15  subdivision 4, is amended to read: 
 12.16     Subd. 4.  [ADDITIONAL INFORMATION.] A utilization review 
 12.17  organization may request information in addition to that 
 12.18  described in subdivision 3 when there is significant lack of 
 12.19  agreement between the utilization review organization and the 
 12.20  health care provider regarding the appropriateness of 
 12.21  certification during the review or appeal process.  For purposes 
 12.22  of this subdivision, "significant lack of agreement" means that 
 12.23  the utilization review organization has: 
 12.24     (1) tentatively determined through its professional staff 
 12.25  that a service cannot be certified; 
 12.26     (2) referred the case to a physician for review; and 
 12.27     (3) talked to or attempted to talk to the attending 
 12.28  physician health care professional for further information. 
 12.29     Nothing in sections 62M.01 to 62M.16 prohibits a 
 12.30  utilization review organization from requiring submission of 
 12.31  data necessary to comply with the quality assurance and 
 12.32  utilization review requirements of chapter 62D or other 
 12.33  appropriate data or outcome analyses. 
 12.34     Sec. 23.  Minnesota Statutes 1998, section 62M.05, is 
 12.35  amended to read: 
 12.36     62M.05 [PROCEDURES FOR REVIEW DETERMINATION.] 
 13.1      Subdivision 1.  [WRITTEN PROCEDURES.] A utilization review 
 13.2   organization must have written procedures to ensure that reviews 
 13.3   are conducted in accordance with the requirements of this 
 13.4   chapter and section 72A.201, subdivision 4a. 
 13.5      Subd. 2.  [CONCURRENT REVIEW.] A utilization review 
 13.6   organization may review ongoing inpatient stays based on the 
 13.7   severity or complexity of the patient's enrollee's condition or 
 13.8   on necessary treatment or discharge planning activities.  Such 
 13.9   review must not be consistently conducted on a daily basis. 
 13.10     Subd. 3.  [NOTIFICATION OF DETERMINATIONS.] A utilization 
 13.11  review organization must have written procedures for providing 
 13.12  notification of its determinations on all certifications in 
 13.13  accordance with the following: this section. 
 13.14     Subd. 3a.  [STANDARD REVIEW DETERMINATION.] (a) 
 13.15  Notwithstanding subdivision 3b, an initial determination on all 
 13.16  requests for utilization review must be communicated to the 
 13.17  provider and enrollee in accordance with this subdivision within 
 13.18  ten business days of the request, provided that all information 
 13.19  reasonably necessary to make a determination on the request has 
 13.20  been made available to the utilization review organization.  
 13.21     (b) When an initial determination is made to certify, 
 13.22  notification must be provided promptly by telephone to the 
 13.23  provider.  The utilization review organization shall send 
 13.24  written notification to the hospital, attending physician, or 
 13.25  applicable service provider within ten business days of the 
 13.26  determination in accordance with section 72A.201, subdivision 
 13.27  4a, provider or shall maintain an audit trail of the 
 13.28  determination and telephone notification.  For purposes of this 
 13.29  subdivision, "audit trail" includes documentation of the 
 13.30  telephone notification, including the date; the name of the 
 13.31  person spoken to; the enrollee or patient; the service, 
 13.32  procedure, or admission certified; and the date of the service, 
 13.33  procedure, or admission.  If the utilization review organization 
 13.34  indicates certification by use of a number, the number must be 
 13.35  called the "certification number." 
 13.36     (b) (c) When a an initial determination is made not to 
 14.1   certify a hospital or surgical facility admission or extension 
 14.2   of a hospital stay, or other service requiring review 
 14.3   determination, notification must be provided by telephone within 
 14.4   one working day after making the decision determination to the 
 14.5   attending physician health care professional and hospital must 
 14.6   be notified by telephone and a written notification must be sent 
 14.7   to the hospital, attending physician health care professional, 
 14.8   and enrollee or patient.  The written notification must include 
 14.9   the principal reason or reasons for the determination and the 
 14.10  process for initiating an appeal of the determination.  Upon 
 14.11  request, the utilization review organization shall provide 
 14.12  the attending physician or provider or enrollee with the 
 14.13  criteria used to determine the necessity, appropriateness, and 
 14.14  efficacy of the health care service and identify the database, 
 14.15  professional treatment parameter, or other basis for the 
 14.16  criteria.  Reasons for a determination not to certify may 
 14.17  include, among other things, the lack of adequate information to 
 14.18  certify after a reasonable attempt has been made to contact 
 14.19  the attending physician provider or enrollee. 
 14.20     (d) When an initial determination is made not to certify, 
 14.21  the written notification must inform the enrollee and the 
 14.22  attending health care professional of the right to submit an 
 14.23  appeal to the internal appeal process described in section 
 14.24  62M.06 and the procedure for initiating the internal appeal. 
 14.25     Subd. 3b.  [EXPEDITED REVIEW DETERMINATION.] (a) An 
 14.26  expedited initial determination must be utilized if the 
 14.27  attending health care professional believes that an expedited 
 14.28  determination is warranted. 
 14.29     (b) Notification of an expedited initial determination to 
 14.30  either certify or not to certify must be provided to the 
 14.31  hospital, the attending health care professional, and the 
 14.32  enrollee as expeditiously as the enrollee's medical condition 
 14.33  requires, but no later than 72 hours from the initial request.  
 14.34  When an expedited initial determination is made not to certify, 
 14.35  the utilization review organization must also notify the 
 14.36  enrollee and the attending health care professional of the right 
 15.1   to submit an appeal to the expedited internal appeal as 
 15.2   described in section 62M.06 and the procedure for initiating an 
 15.3   internal expedited appeal. 
 15.4      Subd. 4.  [FAILURE TO PROVIDE NECESSARY INFORMATION.] A 
 15.5   utilization review organization must have written procedures to 
 15.6   address the failure of a health care provider, patient, or 
 15.7   representative of either or enrollee to provide the necessary 
 15.8   information for review.  If the patient enrollee or provider 
 15.9   will not release the necessary information to the utilization 
 15.10  review organization, the utilization review organization may 
 15.11  deny certification in accordance with its own policy or the 
 15.12  policy described in the health benefit plan. 
 15.13     Subd. 5.  [NOTIFICATION TO CLAIMS ADMINISTRATOR.] If the 
 15.14  utilization review organization and the claims administrator are 
 15.15  separate entities, the utilization review organization must 
 15.16  forward, electronically or in writing, a notification of 
 15.17  certification or determination not to certify to the appropriate 
 15.18  claims administrator for the health benefit plan. 
 15.19     Sec. 24.  Minnesota Statutes 1998, section 62M.06, is 
 15.20  amended to read: 
 15.21     62M.06 [APPEALS OF DETERMINATIONS NOT TO CERTIFY.] 
 15.22     Subdivision 1.  [PROCEDURES FOR APPEAL.] A utilization 
 15.23  review organization must have written procedures for appeals of 
 15.24  determinations not to certify an admission, procedure, service, 
 15.25  or extension of stay.  The right to appeal must be available to 
 15.26  the enrollee or designee and to the attending physician health 
 15.27  care professional.  The right of appeal must be communicated to 
 15.28  the enrollee or designee or to the attending physician, whomever 
 15.29  initiated the original certification request, at the time that 
 15.30  the original determination is communicated. 
 15.31     Subd. 2.  [EXPEDITED APPEAL.] (a) When an initial 
 15.32  determination not to certify a health care service is made prior 
 15.33  to or during an ongoing service requiring review, and the 
 15.34  attending physician health care professional believes that the 
 15.35  determination warrants immediate an expedited appeal, the 
 15.36  utilization review organization must ensure that the enrollee 
 16.1   and the attending physician, enrollee, or designee has health 
 16.2   care professional have an opportunity to appeal the 
 16.3   determination over the telephone on an expedited basis.  In such 
 16.4   an appeal, the utilization review organization must ensure 
 16.5   reasonable access to its consulting physician or health care 
 16.6   provider.  Expedited appeals that are not resolved may be 
 16.7   resubmitted through the standard appeal process. 
 16.8      (b) The utilization review organization shall notify the 
 16.9   enrollee and attending health care professional by telephone of 
 16.10  its determination on the expedited appeal as expeditiously as 
 16.11  the enrollee's medical condition requires, but no later than 72 
 16.12  hours after receiving the expedited appeal. 
 16.13     (c) If the determination not to certify is not reversed 
 16.14  through the expedited appeal, the utilization review 
 16.15  organization must include in its notification the right to 
 16.16  submit the appeal to the external appeal process described in 
 16.17  section 62Q.73 and the procedure for initiating the process.  
 16.18  This information must be provided in writing to the enrollee and 
 16.19  the attending health care professional as soon as practical. 
 16.20     Subd. 3.  [STANDARD APPEAL.] The utilization review 
 16.21  organization must establish procedures for appeals to be made 
 16.22  either in writing or by telephone. 
 16.23     (a) Each A utilization review organization shall notify in 
 16.24  writing the enrollee or patient, attending physician health care 
 16.25  professional, and claims administrator of its determination on 
 16.26  the appeal as soon as practical, but in no case later than 45 
 16.27  days after receiving the required documentation on the 
 16.28  appeal within 30 days upon receipt of the notice of appeal.  If 
 16.29  the utilization review organization cannot make a determination 
 16.30  within 30 days due to circumstances outside the control of the 
 16.31  utilization review organization, the utilization review 
 16.32  organization may take up to 14 additional days to notify the 
 16.33  enrollee, attending health care professional, and claims 
 16.34  administrator of its determination.  If the utilization review 
 16.35  organization takes any additional days beyond the initial 30-day 
 16.36  period to make its determination, it must inform the enrollee, 
 17.1   attending health care professional, and claims administrator, in 
 17.2   advance, of the extension and the reasons for the extension. 
 17.3      (b) The documentation required by the utilization review 
 17.4   organization may include copies of part or all of the medical 
 17.5   record and a written statement from the attending health care 
 17.6   provider professional. 
 17.7      (c) Prior to upholding the original decision initial 
 17.8   determination not to certify for clinical reasons, the 
 17.9   utilization review organization shall conduct a review of the 
 17.10  documentation by a physician who did not make the original 
 17.11  initial determination not to certify. 
 17.12     (d) The process established by a utilization review 
 17.13  organization may include defining a period within which an 
 17.14  appeal must be filed to be considered.  The time period must be 
 17.15  communicated to the patient, enrollee, or and attending 
 17.16  physician health care professional when the initial 
 17.17  determination is made. 
 17.18     (e) An attending physician health care professional or 
 17.19  enrollee who has been unsuccessful in an attempt to reverse a 
 17.20  determination not to certify shall, consistent with section 
 17.21  72A.285, be provided the following: 
 17.22     (1) a complete summary of the review findings; 
 17.23     (2) qualifications of the reviewers, including any license, 
 17.24  certification, or specialty designation; and 
 17.25     (3) the relationship between the enrollee's diagnosis and 
 17.26  the review criteria used as the basis for the decision, 
 17.27  including the specific rationale for the reviewer's decision. 
 17.28     (f) In cases of appeal to reverse a determination not to 
 17.29  certify for clinical reasons, the utilization review 
 17.30  organization must, upon request of the attending physician 
 17.31  health care professional, ensure that a physician of the 
 17.32  utilization review organization's choice in the same or a 
 17.33  similar general specialty as typically manages the medical 
 17.34  condition, procedure, or treatment under discussion is 
 17.35  reasonably available to review the case. 
 17.36     (g) If the initial determination is not reversed on appeal, 
 18.1   the utilization review organization must include in its 
 18.2   notification the right to submit the appeal to the external 
 18.3   review process described in section 62Q.73 and the procedure for 
 18.4   initiating the external process. 
 18.5      Subd. 4.  [NOTIFICATION TO CLAIMS ADMINISTRATOR.] If the 
 18.6   utilization review organization and the claims administrator are 
 18.7   separate entities, the utilization review organization 
 18.8   must forward notify, either electronically or in writing, a 
 18.9   notification of certification or determination not to certify to 
 18.10  the appropriate claims administrator for the health benefit plan 
 18.11  of any determination not to certify that is reversed on appeal. 
 18.12     Sec. 25.  Minnesota Statutes 1998, section 62M.07, is 
 18.13  amended to read: 
 18.14     62M.07 [PRIOR AUTHORIZATION OF SERVICES.] 
 18.15     (a) Utilization review organizations conducting prior 
 18.16  authorization of services must have written standards that meet 
 18.17  at a minimum the following requirements: 
 18.18     (1) written procedures and criteria used to determine 
 18.19  whether care is appropriate, reasonable, or medically necessary; 
 18.20     (2) a system for providing prompt notification of its 
 18.21  determinations to enrollees and providers and for notifying the 
 18.22  provider, enrollee, or enrollee's designee of appeal procedures 
 18.23  under clause (4); 
 18.24     (3) compliance with section 72A.201 62M.05, subdivision 4a 
 18.25  subdivisions 3a and 3b, regarding time frames for approving and 
 18.26  disapproving prior authorization requests; 
 18.27     (4) written procedures for appeals of denials of prior 
 18.28  authorization which specify the responsibilities of the enrollee 
 18.29  and provider, and which meet the requirements of section 
 18.30  sections 62M.06 and 72A.285, regarding release of summary review 
 18.31  findings; and 
 18.32     (5) procedures to ensure confidentiality of 
 18.33  patient-specific information, consistent with applicable law. 
 18.34     (b) No utilization review organization, health plan 
 18.35  company, or claims administrator may conduct or require prior 
 18.36  authorization of emergency confinement or emergency treatment.  
 19.1   The enrollee or the enrollee's authorized representative may be 
 19.2   required to notify the health plan company, claims 
 19.3   administrator, or utilization review organization as soon after 
 19.4   the beginning of the emergency confinement or emergency 
 19.5   treatment as reasonably possible. 
 19.6      Sec. 26.  Minnesota Statutes 1998, section 62M.09, 
 19.7   subdivision 3, is amended to read: 
 19.8      Subd. 3.  [PHYSICIAN REVIEWER INVOLVEMENT.] A physician 
 19.9   must review all cases in which the utilization review 
 19.10  organization has concluded that a determination not to certify 
 19.11  for clinical reasons is appropriate.  The physician should be 
 19.12  reasonably available by telephone to discuss the determination 
 19.13  with the attending physician health care professional.  This 
 19.14  subdivision does not apply to outpatient mental health or 
 19.15  substance abuse services governed by subdivision 3a.  
 19.16     Sec. 27.  Minnesota Statutes 1998, section 62M.10, 
 19.17  subdivision 2, is amended to read: 
 19.18     Subd. 2.  [REVIEWS DURING NORMAL BUSINESS HOURS.] A 
 19.19  utilization review organization must conduct its telephone 
 19.20  reviews, on-site reviews, and hospital communications during 
 19.21  hospitals' and physicians' reasonable and normal business hours, 
 19.22  unless otherwise mutually agreed. 
 19.23     Sec. 28.  Minnesota Statutes 1998, section 62M.10, 
 19.24  subdivision 5, is amended to read: 
 19.25     Subd. 5.  [ORAL REQUESTS FOR INFORMATION.] Utilization 
 19.26  review organizations shall orally inform, upon request, 
 19.27  designated hospital personnel or the attending physician health 
 19.28  care professional of the utilization review requirements of the 
 19.29  specific health benefit plan and the general type of criteria 
 19.30  used by the review agent.  Utilization review organizations 
 19.31  should also orally inform, upon request, hospitals, physicians, 
 19.32  and other health care professionals a provider of the 
 19.33  operational procedures in order to facilitate the review process.
 19.34     Sec. 29.  Minnesota Statutes 1998, section 62M.10, 
 19.35  subdivision 7, is amended to read: 
 19.36     Subd. 7.  [AVAILABILITY OF CRITERIA.] Upon request, a 
 20.1   utilization review organization shall provide to an enrollee or 
 20.2   to an attending physician or a provider the criteria used for a 
 20.3   specific procedure to determine the necessity, appropriateness, 
 20.4   and efficacy of that procedure and identify the database, 
 20.5   professional treatment guideline, or other basis for the 
 20.6   criteria. 
 20.7      Sec. 30.  Minnesota Statutes 1998, section 62M.12, is 
 20.8   amended to read: 
 20.9      62M.12 [PROHIBITION OF INAPPROPRIATE INCENTIVES.] 
 20.10     No individual who is performing utilization review may 
 20.11  receive any financial incentive based on the number of denials 
 20.12  of certifications made by such individual, provided that 
 20.13  utilization review organizations may establish medically 
 20.14  appropriate performance standards.  This prohibition does not 
 20.15  apply to financial incentives established between health plans 
 20.16  plan companies and their providers. 
 20.17     Sec. 31.  Minnesota Statutes 1998, section 62M.15, is 
 20.18  amended to read: 
 20.19     62M.15 [APPLICABILITY OF OTHER CHAPTER REQUIREMENTS.] 
 20.20     The requirements of this chapter regarding the conduct of 
 20.21  utilization review are in addition to any specific requirements 
 20.22  contained in chapter 62A, 62C, 62D, 62Q, 62T, or 72A. 
 20.23     Sec. 32.  Minnesota Statutes 1998, section 62Q.106, is 
 20.24  amended to read: 
 20.25     62Q.106 [DISPUTE RESOLUTION BY COMMISSIONER.] 
 20.26     A complainant may at any time submit a complaint to the 
 20.27  appropriate commissioner to investigate.  After investigating a 
 20.28  complaint, or reviewing a company's decision, the appropriate 
 20.29  commissioner may order a remedy as authorized under section 
 20.30  62Q.30 or chapter 45, 60A, or 62D.  
 20.31     Sec. 33.  Minnesota Statutes 1998, section 62Q.19, 
 20.32  subdivision 5a, is amended to read: 
 20.33     Subd. 5a.  [COOPERATION.] Each health plan company and 
 20.34  essential community provider shall cooperate to facilitate the 
 20.35  use of the essential community provider by the high risk and 
 20.36  special needs populations.  This includes cooperation on the 
 21.1   submission and processing of claims, sharing of all pertinent 
 21.2   records and data, including performance indicators and specific 
 21.3   outcomes data, and the use of all dispute resolution methods as 
 21.4   defined in section 62Q.11, subdivision 1. 
 21.5      Sec. 34.  [62Q.68] [DEFINITIONS.] 
 21.6      Subdivision 1.  [APPLICATION.] For purposes of sections 
 21.7   62Q.68 to 62Q.72, the terms defined in this section have the 
 21.8   meanings given them.  For purposes of sections 62Q.69 and 
 21.9   62Q.70, the term "health plan company" does not include an 
 21.10  insurance company licensed under chapter 60A to offer, sell, or 
 21.11  issue a policy of accident and sickness insurance as defined in 
 21.12  section 62A.01 or a nonprofit health service plan corporation 
 21.13  regulated under chapter 62C that only provides dental coverage 
 21.14  or vision coverage. 
 21.15     Subd. 2.  [COMPLAINT.] "Complaint" means any grievance 
 21.16  against a health plan company that is not the subject of 
 21.17  litigation and that has been submitted by a complainant to a 
 21.18  health plan company regarding the provision of health services 
 21.19  including, but not limited to, the scope of coverage for health 
 21.20  care services; retrospective denials or limitations of payment 
 21.21  for services; eligibility issues; denials, cancellations, or 
 21.22  nonrenewals of coverage; administrative operations; and the 
 21.23  quality, timeliness, and appropriateness of health care services 
 21.24  rendered.  If the complaint is from an applicant, the complaint 
 21.25  must relate to the application.  If the complaint is from a 
 21.26  former enrollee, the complaint must relate to services received 
 21.27  during the period of time the individual was an enrollee.  Any 
 21.28  grievance requiring a medical determination in its resolution 
 21.29  must have the medical determination aspect of the complaint 
 21.30  processed under the appeal procedure described in section 62M.06.
 21.31     Subd. 3.  [COMPLAINANT.] "Complainant" means an enrollee, 
 21.32  applicant, or former enrollee, or anyone acting on behalf of an 
 21.33  enrollee, applicant, or former enrollee who submits a complaint. 
 21.34     Sec. 35.  [62Q.69] [COMPLAINT RESOLUTION.] 
 21.35     Subdivision 1.  [ESTABLISHMENT.] Each health plan company 
 21.36  must establish and maintain an internal complaint resolution 
 22.1   process that meets the requirements of this section to provide 
 22.2   for the resolution of a complaint initiated by a complainant. 
 22.3      Subd. 2.  [PROCEDURES FOR FILING A COMPLAINT.] (a) A 
 22.4   complainant may submit a complaint to a health plan company 
 22.5   either by telephone or in writing.  If a complaint is submitted 
 22.6   orally and the resolution of the complaint, as determined by the 
 22.7   complainant, is partially or wholly adverse to the complainant, 
 22.8   or the oral complaint is not resolved to the satisfaction of the 
 22.9   complainant, by the health plan company within ten days of 
 22.10  receiving the complaint, the health plan company must inform the 
 22.11  complainant that the complaint may be submitted in writing.  The 
 22.12  health plan company must also offer to provide the complainant 
 22.13  with any assistance needed to submit a written complaint, 
 22.14  including an offer to complete the complaint form for a 
 22.15  complaint that was previously submitted orally and promptly mail 
 22.16  the completed form to the complainant for the complainant's 
 22.17  signature.  At the complainant's request, the health plan 
 22.18  company must provide the assistance requested by the 
 22.19  complainant.  The complaint form must include the following 
 22.20  information: 
 22.21     (1) the telephone number of the office of health care 
 22.22  consumer assistance, advocacy, and information, and the health 
 22.23  plan company member services or other departments or persons 
 22.24  equipped to advise complainants on complaint resolution; 
 22.25     (2) the address to which the form must be sent; 
 22.26     (3) a description of the health plan company's internal 
 22.27  complaint procedure and the applicable time limits; and 
 22.28     (4) the toll-free telephone number of either the 
 22.29  commissioner of health or commerce and notification that the 
 22.30  complainant has the right to submit the complaint at any time to 
 22.31  the appropriate commissioner for investigation. 
 22.32     (b) Upon receipt of a written complaint, the health plan 
 22.33  company must notify the complainant within ten business days 
 22.34  that the complaint was received, unless the complaint is 
 22.35  resolved to the satisfaction of the complainant within the ten 
 22.36  business days. 
 23.1      (c) Each health plan company must provide, in the member 
 23.2   handbook, subscriber contract, or certification of coverage, a 
 23.3   clear and concise description of how to submit a complaint and a 
 23.4   statement that, upon request, assistance in submitting a written 
 23.5   complaint is available from the health plan company. 
 23.6      Subd. 3.  [NOTIFICATION OF COMPLAINT DECISIONS.] (a) The 
 23.7   health plan company must notify the complainant in writing of 
 23.8   its decision and the reasons for it as soon as practical but in 
 23.9   no case later than 30 days after receipt of a written complaint. 
 23.10  If the health plan company cannot make a decision within 30 days 
 23.11  due to circumstances outside the control of the health plan 
 23.12  company, the health plan company may take up to 14 additional 
 23.13  days to notify the complainant of its decision.  If the health 
 23.14  plan company takes any additional days beyond the initial 30-day 
 23.15  period to make its decision, it must inform the complainant, in 
 23.16  advance, of the extension and the reasons for the extension.  
 23.17     (b) If the decision is partially or wholly adverse to the 
 23.18  complainant, the notification must inform the complainant of the 
 23.19  right to appeal the decision to the health plan company's 
 23.20  internal appeal process described in section 62Q.70 and the 
 23.21  procedure for initiating an appeal.  
 23.22     (c) The notification must also inform the complainant of 
 23.23  the right to submit the complaint at any time to either the 
 23.24  commissioner of health or commerce for investigation and the 
 23.25  toll-free telephone number of the appropriate commissioner. 
 23.26     Sec. 36.  [62Q.70] [APPEAL OF THE COMPLAINT DECISION.] 
 23.27     Subdivision 1.  [ESTABLISHMENT.] (a) Each health plan 
 23.28  company shall establish an internal appeal process for reviewing 
 23.29  a health plan company's decision regarding a complaint filed in 
 23.30  accordance with section 62Q.69.  The appeal process must meet 
 23.31  the requirements of this section.  
 23.32     (b) The person or persons with authority to resolve or 
 23.33  recommend the resolution of the internal appeal must not be 
 23.34  solely the same person or persons who made the complaint 
 23.35  decision under section 62Q.69. 
 23.36     (c) The internal appeal process must permit the receipt of 
 24.1   testimony, correspondence, explanations, or other information 
 24.2   from the complainant, staff persons, administrators, providers, 
 24.3   or other persons as deemed necessary by the person or persons 
 24.4   investigating or presiding over the appeal. 
 24.5      Subd. 2.  [PROCEDURES FOR FILING AN APPEAL.] If a 
 24.6   complainant notifies the health plan company of the 
 24.7   complainant's desire to appeal the health plan company's 
 24.8   decision regarding the complaint through the internal appeal 
 24.9   process, the health plan company must provide the complainant 
 24.10  the option for the appeal to occur either in writing or by 
 24.11  hearing. 
 24.12     Subd. 3.  [NOTIFICATION OF APPEAL DECISIONS.] (a) If a 
 24.13  complainant appeals in writing, the health plan company must 
 24.14  give the complainant written notice of the appeal decision and 
 24.15  all key findings within 30 days of the health plan company's 
 24.16  receipt of the complainant's written notice of appeal.  If a 
 24.17  complainant appeals by hearing, the health plan company must 
 24.18  give the complainant written notice of the appeal decision and 
 24.19  all key findings within 45 days of the health plan company's 
 24.20  receipt of the complainant's written notice of appeal. 
 24.21     (b) If the appeal decision is partially or wholly adverse 
 24.22  to the complainant, the notice must advise the complainant of 
 24.23  the right to submit the appeal decision to the external review 
 24.24  process described in section 62Q.73 and the procedure for 
 24.25  initiating the external process. 
 24.26     (c) Upon the request of the complainant, the health plan 
 24.27  company must provide the complainant with a complete summary of 
 24.28  the appeal decision.  
 24.29     Sec. 37.  [62Q.71] [NOTICE TO ENROLLEES.] 
 24.30     Each health plan company shall provide to enrollees a clear 
 24.31  and concise description of its complaint resolution procedure, 
 24.32  if applicable under section 62Q.68, subdivision 1, and the 
 24.33  procedure used for utilization review as defined under chapter 
 24.34  62M as part of the member handbook, subscriber contract, or 
 24.35  certificate of coverage.  If the health plan company does not 
 24.36  issue a member handbook, the health plan company may provide the 
 25.1   description in another written document.  The description must 
 25.2   specifically inform enrollees:  
 25.3      (1) how to submit a complaint to the health plan company; 
 25.4      (2) if the health plan includes utilization review 
 25.5   requirements, how to notify the utilization review organization 
 25.6   in a timely manner and how to obtain certification for health 
 25.7   care services; 
 25.8      (3) how to request an appeal either through the procedures 
 25.9   described in sections 62Q.69 and 62Q.70 or through the 
 25.10  procedures described in chapter 62M; 
 25.11     (4) of the right to file a complaint with either the 
 25.12  commissioner of health or commerce at any time during the 
 25.13  complaint and appeal process; 
 25.14     (5) the toll-free telephone number of the appropriate 
 25.15  commissioner; 
 25.16     (6) the telephone number of the office of consumer 
 25.17  assistance, advocacy, and information; and 
 25.18     (7) of the right to obtain an external review under section 
 25.19  62Q.73 and a description of when and how that right may be 
 25.20  exercised. 
 25.21     Sec. 38.  [62Q.72] [RECORDKEEPING; REPORTING.] 
 25.22     Subdivision 1.  [RECORDKEEPING.] Each health plan company 
 25.23  shall maintain records of all enrollee complaints and their 
 25.24  resolutions.  These records shall be retained for five years and 
 25.25  shall be made available to the appropriate commissioner upon 
 25.26  request.  An insurance company licensed under chapter 60A may 
 25.27  instead comply with section 72A.20, subdivision 30. 
 25.28     Subd. 2.  [REPORTING.] Each health plan company shall 
 25.29  submit to the appropriate commissioner, as part of the company's 
 25.30  annual filing, data on the number and type of complaints that 
 25.31  are not resolved within 30 days, or 30 business days as provided 
 25.32  under section 72A.201, subdivision 4, clause (3), for insurance 
 25.33  companies licensed under chapter 60A.  The commissioner shall 
 25.34  also make this information available to the public upon request. 
 25.35     Sec. 39.  [62Q.73] [EXTERNAL REVIEW OF ADVERSE 
 25.36  DETERMINATIONS.] 
 26.1      Subdivision 1.  [DEFINITION.] For purposes of this section, 
 26.2   adverse determination means:  
 26.3      (1) a complaint decision relating to a health care service 
 26.4   or claim that has been appealed in accordance with section 
 26.5   62Q.70 and the appeal decision is partially or wholly adverse to 
 26.6   the complainant; 
 26.7      (2) any initial determination not to certify that has been 
 26.8   appealed in accordance with section 62M.06 and the appeal did 
 26.9   not reverse the initial determination not to certify; or 
 26.10     (3) a decision relating to a health care service made by a 
 26.11  health plan company licensed under chapter 60A that denies the 
 26.12  service on the basis that the service was not medically 
 26.13  necessary. 
 26.14  An adverse determination does not include complaints relating to 
 26.15  fraudulent marketing practices or agent misrepresentation. 
 26.16     Subd. 2.  [EXCEPTION.] (a) This section does not apply to 
 26.17  governmental programs except as permitted under paragraph (b).  
 26.18  For purposes of this subdivision, "governmental programs" means 
 26.19  the prepaid medical assistance program, the MinnesotaCare 
 26.20  program, the prepaid general assistance medical care program, 
 26.21  and the federal Medicare program. 
 26.22     (b) In the course of a recipient's appeal of a medical 
 26.23  determination to the commissioner of human services under 
 26.24  section 256.045, the recipient may request an expert medical 
 26.25  opinion be arranged by the external review entity under contract 
 26.26  to provide independent external reviews under this section.  If 
 26.27  such a request is made, the cost of the review shall be paid by 
 26.28  the commissioner of human services.  Any medical opinion 
 26.29  obtained under this paragraph shall only be used by a state 
 26.30  human services referee as evidence in the recipient's appeal to 
 26.31  the commissioner of human services under section 256.045.  
 26.32     (c) Nothing in this subdivision shall be construed to limit 
 26.33  or restrict the appeal rights provided in section 256.045 for 
 26.34  governmental program recipients. 
 26.35     Subd. 3.  [RIGHT TO EXTERNAL REVIEW.] (a) Any enrollee or 
 26.36  anyone acting on behalf of an enrollee who has received an 
 27.1   adverse determination may submit a written request for an 
 27.2   external review of the adverse determination, if applicable 
 27.3   under section 62Q.68, subdivision 1, or 62M.06, to the 
 27.4   commissioner of health if the request involves a health plan 
 27.5   company regulated by that commissioner or to the commissioner of 
 27.6   commerce if the request involves a health plan company regulated 
 27.7   by that commissioner.  The written request must be accompanied 
 27.8   by a filing fee of $25.  The fee may be waived by the 
 27.9   commissioner of health or commerce in cases of financial 
 27.10  hardship. 
 27.11     (b) Nothing in this section requires the commissioner of 
 27.12  health or commerce to independently investigate an adverse 
 27.13  determination referred for independent external review. 
 27.14     (c) If an enrollee requests an external review, the health 
 27.15  plan company must participate in the external review.  The cost 
 27.16  of the external review in excess of the filing fee described in 
 27.17  paragraph (a) shall be borne by the health plan company.  
 27.18     Subd. 4.  [CONTRACT.] Pursuant to a request for proposal, 
 27.19  the commissioner of administration, in consultation with the 
 27.20  commissioners of health and commerce, shall contract with an 
 27.21  organization or business entity to provide independent external 
 27.22  reviews of all adverse determinations submitted for external 
 27.23  review.  The contract shall ensure that the fees for services 
 27.24  rendered in connection with the reviews be reasonable. 
 27.25     Subd. 5.  [CRITERIA.] (a) The request for proposal must 
 27.26  require that the entity demonstrate: 
 27.27     (1) no conflicts of interest in that it is not owned, a 
 27.28  subsidiary of, or affiliated with a health plan company or 
 27.29  utilization review organization; 
 27.30     (2) an expertise in dispute resolution; 
 27.31     (3) an expertise in health related law; 
 27.32     (4) an ability to conduct reviews using a variety of 
 27.33  alternative dispute resolution procedures depending upon the 
 27.34  nature of the dispute; 
 27.35     (5) an ability to provide data to the commissioners of 
 27.36  health and commerce on reviews conducted; and 
 28.1      (6) an ability to ensure confidentiality of medical records 
 28.2   and other enrollee information. 
 28.3      (b) The commissioner of administration shall take into 
 28.4   consideration, in awarding the contract according to subdivision 
 28.5   4, any national accreditation standards that pertain to an 
 28.6   external review entity. 
 28.7      Subd. 6.  [PROCESS.] (a) Upon receiving a request for an 
 28.8   external review, the external review entity must provide 
 28.9   immediate notice of the review to the enrollee and to the health 
 28.10  plan company.  Within ten business days of receiving notice of 
 28.11  the review the health plan company and the enrollee must provide 
 28.12  the external review entity with any information that they wish 
 28.13  to be considered.  Each party shall be provided an opportunity 
 28.14  to present its version of the facts and arguments.  An enrollee 
 28.15  may be assisted or represented by a person of the enrollee's 
 28.16  choice. 
 28.17     (b) As part of the external review process, any aspect of 
 28.18  an external review involving a medical determination must be 
 28.19  performed by a health care professional with expertise in the 
 28.20  medical issue being reviewed. 
 28.21     (c) An external review shall be made as soon as practical 
 28.22  but in no case later than 40 days after receiving the request 
 28.23  for an external review and must promptly send written notice of 
 28.24  the decision and the reasons for it to the enrollee, the health 
 28.25  plan company, and to the commissioner who is responsible for 
 28.26  regulating the health plan company. 
 28.27     Subd. 7.  [STANDARDS OF REVIEW.] (a) For an external review 
 28.28  of any issue in an adverse determination that does not require a 
 28.29  medical necessity determination, the external review must be 
 28.30  based on whether the adverse determination was in compliance 
 28.31  with the enrollee's health benefit plan. 
 28.32     (b) For an external review of any issue in an adverse 
 28.33  determination by a health plan company licensed under chapter 
 28.34  62D that requires a medical necessity determination, the 
 28.35  external review must determine whether the adverse determination 
 28.36  was consistent with the definition of medically necessary care 
 29.1   in Minnesota Rules, part 4685.0100, subpart 9b. 
 29.2      (c) For an external review of any issue in an adverse 
 29.3   determination by a health plan company, other than a health plan 
 29.4   company licensed under chapter 62D, that requires a medical 
 29.5   necessity determination, the external review must determine 
 29.6   whether the adverse determination was consistent with the 
 29.7   definition of medically necessary care in section 62Q.53, 
 29.8   subdivision 2. 
 29.9      Subd. 8.  [EFFECTS OF EXTERNAL REVIEW.] A decision rendered 
 29.10  under this section shall be nonbinding on the enrollee and 
 29.11  binding on the health plan company.  The health plan company may 
 29.12  seek judicial review of the decision on the grounds that the 
 29.13  decision was arbitrary and capricious or involved an abuse of 
 29.14  discretion. 
 29.15     Subd. 9.  [IMMUNITY FROM CIVIL LIABILITY.] A person who 
 29.16  participates in an external review by investigating, reviewing 
 29.17  materials, providing technical expertise, or rendering a 
 29.18  decision shall not be civilly liable for any action that is 
 29.19  taken in good faith, that is within the scope of the person's 
 29.20  duties, and that does not constitute willful or reckless 
 29.21  misconduct. 
 29.22     Subd. 10.  [DATA REPORTING.] The commissioners shall make 
 29.23  available to the public, upon request, summary data on the 
 29.24  decisions rendered under this section, including the number of 
 29.25  reviews heard and decided and the final outcomes.  Any data 
 29.26  released to the public must not individually identify the 
 29.27  enrollee initiating the request for external review. 
 29.28     Sec. 40.  Minnesota Statutes 1998, section 62T.04, is 
 29.29  amended to read: 
 29.30     62T.04 [COMPLAINT SYSTEM.] 
 29.31     Accountable provider networks must establish and maintain 
 29.32  an enrollee complaint system as required under section 
 29.33  62Q.105 sections 62Q.68 to 62Q.72.  The accountable provider 
 29.34  network may contract with the health care purchasing alliance or 
 29.35  a vendor for operation of this system. 
 29.36     Sec. 41.  Minnesota Statutes 1998, section 72A.201, 
 30.1   subdivision 4a, is amended to read: 
 30.2      Subd. 4a.  [STANDARDS FOR PREAUTHORIZATION APPROVAL.] If a 
 30.3   policy of accident and sickness insurance or a subscriber 
 30.4   contract requires preauthorization approval for any nonemergency 
 30.5   services or benefits, the decision to approve or disapprove the 
 30.6   requested services or benefits must be communicated to the 
 30.7   insured or the insured's health care provider within ten 
 30.8   business days of the preauthorization request provided that all 
 30.9   information reasonably necessary to make a decision on the 
 30.10  request has been made available to the insurer processed in 
 30.11  accordance with section 62M.07. 
 30.12     Sec. 42.  Minnesota Statutes 1998, section 256B.692, 
 30.13  subdivision 2, is amended to read: 
 30.14     Subd. 2.  [DUTIES OF THE COMMISSIONER OF HEALTH.] 
 30.15  Notwithstanding chapters 62D and 62N, a county that elects to 
 30.16  purchase medical assistance and general assistance medical care 
 30.17  in return for a fixed sum without regard to the frequency or 
 30.18  extent of services furnished to any particular enrollee is not 
 30.19  required to obtain a certificate of authority under chapter 62D 
 30.20  or 62N.  A county that elects to purchase medical assistance and 
 30.21  general assistance medical care services under this section must 
 30.22  satisfy the commissioner of health that the requirements of 
 30.23  chapter 62D, applicable to health maintenance organizations, or 
 30.24  chapter 62N, applicable to community integrated service 
 30.25  networks, will be met.  A county must also assure the 
 30.26  commissioner of health that the requirements of sections 
 30.27  62J.041; 62J.48; 62J.71 to 62J.73; 62M.01 to 62M.16; all 
 30.28  applicable provisions of chapter 62Q, including sections 62Q.07; 
 30.29  62Q.075; 62Q.105; 62Q.1055; 62Q.106; 62Q.11; 62Q.12; 62Q.135; 
 30.30  62Q.14; 62Q.145; 62Q.19; 62Q.23, paragraph (c); 62Q.30; 62Q.43; 
 30.31  62Q.47; 62Q.50; 62Q.52 to 62Q.56; 62Q.58; 62Q.64; 62Q.68 to 
 30.32  62Q.72; and 72A.201 will be met.  All enforcement and rulemaking 
 30.33  powers available under chapters 62D, 62J, 62M, 62N, and 62Q are 
 30.34  hereby granted to the commissioner of health with respect to 
 30.35  counties that purchase medical assistance and general assistance 
 30.36  medical care services under this section. 
 31.1      Sec. 43.  [REPEALER.] 
 31.2      (a) Minnesota Statutes 1998, section 62D.11, subdivisions 
 31.3   1b and 2, are repealed.  
 31.4      (b) Minnesota Statutes 1998, sections 62Q.105; 62Q.11; and 
 31.5   62Q.30, are repealed. 
 31.6      (c) Minnesota Rules, parts 4685.0100, subparts 4 and 4a; 
 31.7   and 4685.1700, are repealed. 
 31.8      (d) Minnesota Rules, part 4685.1010, subpart 3, is repealed.
 31.9      Sec. 44.  [EFFECTIVE DATE.] 
 31.10     Sections 1, 3 to 42, and 43, paragraphs (a) and (c), are 
 31.11  effective April 1, 2000, and apply to contracts issued or 
 31.12  renewed on or after that date.  Upon request, the commissioner 
 31.13  of health or commerce shall grant an extension of up to three 
 31.14  months to any health plan company or utilization review 
 31.15  organization that is unable to comply with sections 1, 3 to 42, 
 31.16  and 43, paragraphs (a) and (c) by April 1, 2000, due to 
 31.17  circumstances beyond the control of the health plan company or 
 31.18  utilization review organization.  
 31.19     Section 43, paragraph (b), is effective July 1, 1999. 
 31.20     Sections 2 and 43, paragraph (d), are effective January 1, 
 31.21  2000, and apply to contracts issued or renewed on or after that 
 31.22  date.