SF 3204

as introduced - 91st Legislature (2019 - 2020) Posted on 05/07/2020 12:30pm

A bill for an act
relating to health care coverage; modifying requirements governing utilization
review and prior authorization of health care services; making conforming changes;
amending Minnesota Statutes 2018, sections 62M.01, subdivision 2; 62M.02,
subdivisions 2, 5, 8, 20, 21, by adding subdivisions; 62M.04, subdivisions 1, 2, 3,
4; 62M.05, subdivisions 3, 3a, 4, 5, by adding a subdivision; 62M.06, subdivisions
1, 3, 4; 62M.07; 62M.09, subdivisions 3, 3a, 4, 4a, 5; 62M.10, subdivision 7, by
adding a subdivision; 62M.11; 62M.12; 62M.14; 62Q.71; 62Q.73, subdivision 1;
256B.0625, subdivision 25; proposing coding for new law in Minnesota Statutes,
chapters 62A; 62M; repealing Minnesota Statutes 2018, sections 62D.12,
subdivision 19; 62M.02, subdivision 19; 62M.05, subdivision 3b; 62M.06,
subdivision 2.

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

ARTICLE 1

UTILIZATION REVIEW AND PRIOR AUTHORIZATION OF HEALTH CARE
SERVICES

Section 1.

new text begin [62A.58] COVERAGE OF SERVICE; PRIOR AUTHORIZATION.
new text end

new text begin A health carrier may not deny or limit coverage of a service the enrollee has already
received solely on the basis of lack of prior authorization or second opinion, to the extent
that the service would otherwise have been covered by the health carrier under the enrollee's
health plan had prior authorization or second opinion been obtained. For purposes of this
section, "prior authorization" has the meaning given in section 62M.02, subdivision 15.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective August 1, 2020, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 2.

Minnesota Statutes 2018, section 62M.01, subdivision 2, is amended to read:

Subd. 2.

Jurisdiction.

deleted text begin Sections 62M.01 to 62M.16 apply deleted text end new text begin This chapter applies new text end to any
insurance company licensed under chapter 60A to offer, sell, or issue a policy of accident
and sickness insurance as defined in section 62A.01; a health service plan licensed under
chapter 62C; a health maintenance organization licensed under chapter 62D; the Minnesota
Comprehensive Health Association created under chapter 62E; a community integrated
service network licensed under chapter 62N; an accountable provider network operating
under chapter 62T; a fraternal benefit society operating under chapter 64B; a joint
self-insurance employee health plan operating under chapter 62H; a multiple employer
welfare arrangement, as defined in section 3 of the Employee Retirement Income Security
Act of 1974 (ERISA), United States Code, title 29, section 1103, as amended; a third-party
administrator licensed under section 60A.23, subdivision 8, that provides utilization review
services for the administration of benefits under a health benefit plan as defined in section
62M.02; new text begin any other individual or entity that provides, offers, or administers hospital,
outpatient, medical, prescription drug, or other health benefits to individuals treated by a
health professional under a policy, plan, or contract; new text end or any entity performing utilization
review on behalf of new text begin an employer with employees in this state who are covered under a health
benefit plan, a health plan company, a preferred provider organization, or new text end a business entity
in this state pursuant to a health benefit plan covering a Minnesota resident.

Sec. 3.

Minnesota Statutes 2018, section 62M.02, is amended by adding a subdivision to
read:

new text begin Subd. 1a. new text end

new text begin Adverse determination. new text end

new text begin "Adverse determination" means a decision by a
utilization review organization to deny, reduce, or terminate coverage for an admission,
extension of stay, or health care service furnished or proposed to be furnished to an enrollee
on the ground that the admission, extension of stay, or health care service is not medically
necessary, is unproven, or is experimental or investigational.
new text end

Sec. 4.

Minnesota Statutes 2018, section 62M.02, subdivision 5, is amended to read:

Subd. 5.

deleted text begin Certification deleted text end new text begin Authorization new text end .

deleted text begin "Certification" deleted text end new text begin "Authorization" new text end means a
determination by a utilization review organization that an admission, extension of stay, or
other health care service has been reviewed and that deleted text begin it deleted text end , based on the information provided,
deleted text begin meets deleted text end new text begin it satisfies new text end the utilization review new text begin organization's new text end requirements deleted text begin of the applicable health
plan and the health plan company will then pay for the covered benefit, provided the
preexisting limitation provisions, the general exclusion provisions, and any deductible,
co-payment, coinsurance, or other policy requirements have been met deleted text end new text begin for medical necessity
and appropriateness and payment will be made for that admission, extension of stay, or
health care service new text end .

Sec. 5.

Minnesota Statutes 2018, section 62M.02, subdivision 8, is amended to read:

Subd. 8.

Clinical criteria.

"Clinical criteria" means the new text begin coverage guidelines, new text end written
policies, deleted text begin decision deleted text end new text begin written screening procedures, drug formularies or lists of covered drugs,
determination new text end rules, new text begin determination abstracts, clinical protocols, practice guidelines, new text end medical
protocols, or deleted text begin guidelines deleted text end new text begin any other criteria or rationale new text end used by the utilization review
organization to determine deleted text begin certification deleted text end new text begin whether a health care service is medically necessary
and appropriate new text end .

Sec. 6.

Minnesota Statutes 2018, section 62M.02, is amended by adding a subdivision to
read:

new text begin Subd. 10a. new text end

new text begin Emergency health care service. new text end

new text begin "Emergency health care service" means a
health care service necessary to treat a medical condition in which the absence of immediate
medical attention could reasonably be expected to result in a condition described in United
States Code, title 42, section 1395dd(e)(1)(A)(i), (ii), or (iii).
new text end

Sec. 7.

Minnesota Statutes 2018, section 62M.02, is amended by adding a subdivision to
read:

new text begin Subd. 12b. new text end

new text begin Health care service. new text end

new text begin "Health care service" means:
new text end

new text begin (1) a health care procedure, treatment, or service provided by a health care facility or a
physician office;
new text end

new text begin (2) a health care procedure, treatment, or service provided by a doctor of medicine,
doctor of osteopathy, or other health professional within the scope of practice for that
professional; or
new text end

new text begin (3) the provision of pharmaceutical products or services, medical supplies, or durable
medical equipment.
new text end

Sec. 8.

Minnesota Statutes 2018, section 62M.02, is amended by adding a subdivision to
read:

new text begin Subd. 13a. new text end

new text begin Medically necessary. new text end

new text begin "Medically necessary" means a health care service
provided to an enrollee:
new text end

new text begin (1) for the purpose of preventing, diagnosing, or treating an illness, injury, or disease or
a symptom of an illness, injury, or disease; and
new text end

new text begin (2) in a manner that is:
new text end

new text begin (i) in accordance with generally accepted standards of medical practice;
new text end

new text begin (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; and
new text end

new text begin (iii) not primarily for the economic benefit of the health plan company or sponsor of the
health benefit plan, or for the convenience of the patient or treating health professional.
new text end

Sec. 9.

Minnesota Statutes 2018, section 62M.02, subdivision 20, is amended to read:

Subd. 20.

Utilization review.

"Utilization review" means the evaluation of the necessity,
appropriateness, and efficacy of the use of health care services, procedures, and facilities,
by a person or entity other than the attending health care professional, for the purpose of
determining the medical necessity of the service or admission. Utilization review also
includes new text begin prior authorization and new text end review conducted after the admission of the enrollee. It
includes situations where the enrollee is unconscious or otherwise unable to provide advance
notification. Utilization review does not include a referral or participation in a referral
process by a participating provider unless the provider is acting as a utilization review
organization.

Sec. 10.

Minnesota Statutes 2018, section 62M.02, subdivision 21, is amended to read:

Subd. 21.

Utilization review organization.

"Utilization review organization" means an
entity including but not limited to an insurance company licensed under chapter 60A to
offer, sell, or issue a policy of accident and sickness insurance as defined in section 62A.01;
a prepaid limited health service organization issued a certificate of authority and operating
under sections 62A.451 to 62A.4528; a health service plan licensed under chapter 62C; a
health maintenance organization licensed under chapter 62D; a community integrated service
network licensed under chapter 62N; an accountable provider network operating under
chapter 62T; a fraternal benefit society operating under chapter 64B; a joint self-insurance
employee health plan operating under chapter 62H; a multiple employer welfare arrangement,
as defined in section 3 of the Employee Retirement Income Security Act of 1974 (ERISA),
United States Code, title 29, section 1103, as amended; a third-party administrator licensed
under section 60A.23, subdivision 8, which conducts utilization review and deleted text begin determines
certification of deleted text end new text begin authorizes or makes adverse determinations regarding new text end an admission, extension
of stay, or other health care services for a Minnesota resident; new text begin any other individual or entity
that provides, offers, or administers hospital, outpatient, medical, prescription drug, or other
health benefits to individuals treated by a health professional under a policy, plan, or contract;
new text end or any entity performing utilization review that is affiliated with, under contract with, or
conducting utilization review on behalf of, new text begin an employer with employees in this state who
are covered under a health benefit plan, a health plan company, a preferred provider
organization, or new text end a business entity in this state. Utilization review organization does not
include a clinic or health care system acting pursuant to a written delegation agreement with
an otherwise regulated utilization review organization that contracts with the clinic or health
care system. The regulated utilization review organization is accountable for the delegated
utilization review activities of the clinic or health care system.

Sec. 11.

Minnesota Statutes 2018, section 62M.04, subdivision 4, is amended to read:

Subd. 4.

Additional information.

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 deleted text begin certification deleted text end new text begin authorization new text end 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 deleted text begin certified deleted text end new text begin
authorized new text end ;

(2) referred the case to a physician for review new text begin and a determination new text end ; and

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

Nothing in deleted text begin sections 62M.01 to 62M.16 deleted text end new text begin this chapter new text end 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. 12.

Minnesota Statutes 2018, section 62M.05, subdivision 3a, is amended to read:

Subd. 3a.

deleted text begin Standard review deleted text end Determination.

(a) deleted text begin Notwithstanding subdivision 3b, An
initial deleted text end new text begin A new text end determination on all requests for utilization review must be communicated to the
provider and enrollee in accordance with this subdivision within deleted text begin ten business days of deleted text end new text begin 36
hours after receiving new text end the request, provided that all information reasonably necessary to make
a determination on the request has been made available to the utilization review organization. new text begin
For purposes of this subdivision and subdivision 4, "information reasonably necessary to
make a determination on the request" must include the results of any face-to-face clinical
evaluation or a second opinion that may be required.
new text end

(b) When deleted text begin an initial deleted text end new text begin a new text end determination is made to deleted text begin certify deleted text end new text begin authorize new text end , 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 deleted text begin certified deleted text end new text begin authorized new text end ; and the
date of the service, procedure, or admission. If the utilization review organization indicates
deleted text begin certification deleted text end new text begin authorization new text end by use of a number, the number must be called the " deleted text begin certification deleted text end new text begin
authorization new text end 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 deleted text begin initial deleted text end new text begin adverse new text end determination is made deleted text begin not to certify deleted text end , notification must be
provided new text begin within 36 hours after receiving the request new text end by telephone, by facsimile to a verified
number, or by electronic mail to a secure electronic mailbox deleted text begin within one working day after
making the determination deleted text end to the attending health care professional and hospital new text begin or physician
office new text end as applicable. Written notification must also be sent to the hospital new text begin or physician office new text end
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. 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 deleted text begin the principal
reason or deleted text end new text begin all new text end reasons new text begin relied on by the utilization review organization new text end 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 deleted text begin a deleted text end new text begin an
adverse new text end determination deleted text begin not to certify deleted text end may include, among other things, the lack of adequate
information to deleted text begin certify deleted text end new text begin authorize new text end after a reasonable attempt has been made to contact the
provider or enrollee.

(d) When an deleted text begin initial deleted text end new text begin adverse new text end determination is made deleted text begin not to certify deleted text end , 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. 13.

Minnesota Statutes 2018, section 62M.05, subdivision 4, is amended to read:

Subd. 4.

Failure to provide necessary information.

A utilization review organization
must have written procedures to address the failure of a provider or enrollee to provide the
deleted text begin necessary deleted text end information deleted text begin for review deleted text end new text begin reasonably necessary to make a determination on the
request new text end . If the enrollee or provider will not release the necessary information to the utilization
review organization, the utilization review organization may deleted text begin deny certification deleted text end new text begin make an
adverse determination new text end in accordance with its own policy or the policy described in the health
benefit plan.

Sec. 14.

Minnesota Statutes 2018, section 62M.05, is amended by adding a subdivision
to read:

new text begin Subd. 6. new text end

new text begin Authorization; primary service in bundle of services. new text end

new text begin If a utilization review
organization authorizes the primary health care service in a bundle of services for which a
bundled payment is charged, all other health care services included in that bundle of services
are deemed to be authorized.
new text end

Sec. 15.

Minnesota Statutes 2018, section 62M.06, subdivision 3, is amended to read:

Subd. 3.

deleted text begin Standard deleted text end Appeal.

(a) The utilization review organization must establish
procedures for appeals to be made either in writing or by telephone.

(b) A utilization review organization shall notify in writing the enrollee, attending health
care professional, and claims administrator of its determination on the appeal within deleted text begin 30
days upon deleted text end new text begin 72 hours after new text end receipt of the notice of appeal. If the utilization review organization
cannot make a determination within deleted text begin 30 days deleted text end new text begin 72 hours new text end due to circumstances outside the
control of the utilization review organization, the utilization review organization may take
up to deleted text begin 14 deleted text end new text begin 72 new text end additional deleted text begin days deleted text end new text begin hours new text end to notify the enrollee, attending health care professional,
and claims administrator of its determination. If the utilization review organization takes
any additional days beyond the initial deleted text begin 30-day deleted text end new text begin 72-hour new text end period to make its determination, it
must inform the enrollee, attending health care professional, and claims administrator, in
advance, of the extension and the reasons for the extension.

(c) The documentation required by the utilization review organization may include copies
of part or all of the medical record and a written statement from the attending health care
professional.

(d) Prior to upholding the deleted text begin initial deleted text end new text begin adverse new text end determination deleted text begin not to certify deleted text end for clinical reasons,
the utilization review organization shall conduct a review of the documentation by a physician
who did not make the deleted text begin initial deleted text end new text begin adverse new text end determination deleted text begin not to certify deleted text end .

(e) The process established by a utilization review organization may include defining a
period within which an appeal must be filed to be considered. The time period must be
communicated to the enrollee and attending health care professional when the deleted text begin initial deleted text end
determination is made.

(f) An attending health care professional or enrollee who has been unsuccessful in an
attempt to reverse deleted text begin a deleted text end new text begin an adverse new text end determination deleted text begin not to certify deleted text end shall, consistent with section
72A.285, be provided the following:

(1) a complete summary of the review findings;

(2) qualifications of the reviewers, including any license, certification, or specialty
designation; and

(3) the relationship between the enrollee's diagnosis and the review criteria used as the
basis for the decision, including the specific rationale for the reviewer's decision.

(g) In cases of appeal to reverse deleted text begin a deleted text end new text begin an adverse new text end determination deleted text begin not to certify deleted text end for clinical
reasons, the utilization review organization must ensure that a physician of the utilization
review organization's choice in the same or a similar specialty as typically manages the
medical condition, procedure, or treatment under discussion is reasonably available to review
the case.

(h) If the deleted text begin initial deleted text end determination is not reversed on appeal, the utilization review organization
must include in its notification the right to submit the appeal to the external review process
described in section 62Q.73 and the procedure for initiating new text begin an appeal under new text end the external
process.

Sec. 16.

Minnesota Statutes 2018, section 62M.07, is amended to read:

62M.07 PRIOR AUTHORIZATION OF SERVICES.

new text begin Subdivision 1. new text end

new text begin Written standards. new text end

deleted text begin (a) deleted text end Utilization review organizations conducting prior
authorization of services must have written standards that meet at a minimum the following
requirements:

(1) written procedures and criteria used to determine whether care is appropriate,
reasonable, or medically necessary;

(2) a system for providing prompt notification of its determinations to enrollees and
providers and for notifying the provider, enrollee, or enrollee's designee of appeal procedures
under clause (4);

(3) compliance with section 62M.05, deleted text begin subdivisions deleted text end new text begin subdivision new text end 3a deleted text begin and 3b deleted text end , regarding time
frames for deleted text begin approving and disapproving deleted text end new text begin authorizing and making adverse determinations
regarding new text end prior authorization requests;

(4) written procedures deleted text begin for appeals of denials deleted text end new text begin to appeal adverse determinations new text end of prior
authorization new text begin requests new text end which specify the responsibilities of the enrollee and provider, and
which meet the requirements of sections 62M.06 and 72A.285, regarding release of summary
review findings; and

(5) procedures to ensure confidentiality of patient-specific information, consistent with
applicable law.

new text begin Subd. 2. new text end

new text begin Prior authorization of emergency services prohibited. new text end

deleted text begin (b) deleted text end No utilization
review organization, health plan company, or claims administrator may conduct or require
prior authorization of emergency confinement or new text begin an new text end emergency deleted text begin treatment deleted text end new text begin health care service new text end .
The enrollee or the enrollee's authorized representative may be required to notify the health
plan company, claims administrator, or utilization review organization as soon new text begin as reasonably
possible new text end after the beginning of the emergency confinement or emergency deleted text begin treatment as
reasonably possible deleted text end new text begin health care service new text end .

new text begin Subd. 3. new text end

new text begin Retrospective revocation or limitation of prior authorization. new text end

new text begin 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.
new text end

new text begin Subd. 4. new text end

new text begin Submission of prior authorization requests. new text end

deleted text begin (c) deleted text end If prior authorization for a
health care service is required, the utilization review organization, health plan company, or
claim administrator must allow providers to submit requests for prior authorization of the
health care services without unreasonable delay by telephone, facsimile, or voice mail or
through deleted text begin an deleted text end new text begin the uniform electronic prior authorization form developed by the commissioner
of health or another new text end electronic mechanism 24 hours a day, seven days a week. This paragraph
does not apply to dental service covered under MinnesotaCare or medical assistance.

new text begin EFFECTIVE DATE. new text end

new text begin Subdivision 4 is effective January 1, 2022.
new text end

Sec. 17.

Minnesota Statutes 2018, section 62M.09, subdivision 3, is amended to read:

Subd. 3.

Physician reviewer deleted text begin involvement deleted text end new text begin ; determinations new text end .

(a) A physician must review
new text begin and make the determination under section 62M.05 in new text end all cases in which the utilization review
organization has concluded that deleted text begin a deleted text end new text begin an adverse new text end determination deleted text begin not to certify deleted text end for clinical reasons
is appropriate.

(b) The physician conducting the review new text begin and making the determination new text end must deleted text begin be licensed deleted text end new text begin :
new text end

new text begin (1) hold a current, unrestricted license to practice medicine new text end in this state deleted text begin . deleted text end new text begin ;and
new text end

new text begin (2) have experience treating patients with the illness, injury, or disease for which the
health care service has been requested.
new text end

This paragraph does not apply to reviews conducted in connection with policies issued by
a health plan company that is assessed less than three percent of the total amount assessed
by the Minnesota Comprehensive Health Association.

(c) The physician should be reasonably available by telephone to discuss the determination
with the attending health care professional.

(d) This subdivision does not apply to outpatient mental health or substance abuse
services governed by subdivision 3a.

Sec. 18.

Minnesota Statutes 2018, section 62M.10, subdivision 7, is amended to read:

Subd. 7.

Availability of criteria.

deleted text begin Upon request, deleted text end new text begin (a) For utilization review determinations
other than prior authorization new text end a utilization review organization shall new text begin , upon request, new text end provide
to an enrollee, a provider, and the commissioner of commerce the criteria used to determine
the medical necessity, appropriateness, and efficacy of a procedure or service and identify
the database, professional treatment guideline, or other basis for the criteria.

new text begin (b) For prior authorization determinations, a utilization review organization must submit
the organization's current prior authorization requirements and restrictions, including all
written, evidence-based, clinical criteria used to make an authorization or adverse
determination, to all health plan companies for which the organization performs utilization
review. A health plan company must post on its public website the prior authorization
requirements and restrictions of any utilization review organization that performs utilization
review for the health plan company. These prior authorization requirements and restrictions
must be detailed and written in easily understandable language.
new text end

Sec. 19.

Minnesota Statutes 2018, section 62M.10, is amended by adding a subdivision
to read:

new text begin Subd. 8. new text end

new text begin Notice; new prior authorization requirements or restrictions; change to
existing requirement or restriction. new text end

new text begin (a) Before a utilization review organization may
implement a new prior authorization requirement or restriction or amend an existing prior
authorization requirement or restriction, the utilization review organization must submit the
new or amended requirement or restriction to all health plan companies for which the
organization performs utilization review and must ensure that the public websites of these
health plan companies are updated with the new or amended requirement or restriction.
new text end

new text begin (b) At least 60 days before a utilization review organization implements a new prior
authorization requirement or restriction or amends an existing prior authorization requirement
or restriction, the utilization review organization must provide written notice of the new or
amended requirement or restriction to all attending health care professionals who are subject
to the utilization review organization's prior authorization requirements and restrictions.
new text end

Sec. 20.

Minnesota Statutes 2018, section 62M.11, is amended to read:

62M.11 COMPLAINTS TO COMMERCE OR HEALTH.

Notwithstanding the provisions of deleted text begin sections 62M.01 to 62M.16 deleted text end new text begin this chapter new text end , an enrollee
new text begin or attending health care professional new text end may file a complaint regarding deleted text begin a deleted text end new text begin an adverse new text end
determination deleted text begin not to certify deleted text end directly to the commissioner responsible for regulating the
utilization review organization.

Sec. 21.

Minnesota Statutes 2018, section 62M.14, is amended to read:

62M.14 EFFECT OF COMPLIANCE new text begin OR NONCOMPLIANCE new text end .

new text begin If a utilization review organization or health plan company fails to comply with a
requirement in this chapter for conducting utilization review of an inpatient admission,
extension of stay, or health care service, that inpatient admission, extension of stay, or health
care service is automatically deemed to be authorized. new text end Evidence of a utilization review
organization's compliance or noncompliance with the provisions of deleted text begin sections 62M.01 to
62M.16 deleted text end new text begin this chapter new text end shall not be determinative in an action alleging that services denied
were deleted text begin medically necessary and deleted text end covered under the terms of the enrollee's health benefit plan.

Sec. 22.

new text begin [62M.17] CONTINUITY OF CARE; PRIOR AUTHORIZATIONS.
new text end

new text begin Subdivision 1. new text end

new text begin Compliance with prior authorization approved by previous utilization
review organization; change in health plan company. new text end

new text begin If an enrollee obtains coverage
from a new health plan company and the health plan company for the enrollee's new health
benefit plan uses a different utilization review organization from the enrollee's previous
health benefit plan to conduct utilization review, the health plan company for the enrollee's
new health benefit plan shall comply with a prior authorization for health care services
approved by the utilization review organization used by the enrollee's previous health benefit
plan for at least the first 60 days that the enrollee is covered under the new health benefit
plan. In order to obtain coverage for this 60-day time period, the enrollee or the enrollee's
attending health care professional must submit documentation of the previous prior
authorization to the enrollee's new health plan company according to procedures in the
enrollee's new health benefit plan. During this 60-day time period, the utilization review
organization used by the enrollee's new health plan company may conduct its own utilization
review of these health care services.
new text end

new text begin Subd. 2. new text end

new text begin Compliance with prior authorization; change in health benefit plan. new text end

new text begin If an
enrollee enrolls in a new health benefit plan issued by the health plan company that also
issued the enrollee's previous health benefit plan, the health plan company shall comply
with any prior authorizations approved for the enrollee while covered under the previous
health benefit plan.
new text end

new text begin Subd. 3. new text end

new text begin Effect of change in prior authorization clinical criteria. new text end

new text begin If, during a plan
year, a utilization review organization changes coverage terms for a health care service or
the clinical criteria used to conduct prior authorizations for a health care service, a utilization
review organization shall not apply the change in coverage terms or change in clinical
criteria until the next plan year for any enrollee who received prior authorization for a health
care service using the coverage terms or clinical criteria in effect before the effective date
of the change.
new text end

Sec. 23.

new text begin [62M.18] ANNUAL POSTING ON WEBSITE; PRIOR AUTHORIZATIONS.
new text end

new text begin (a) By August 1, 2021, and each August 1 thereafter, a health plan company must post
on the health plan company's public website, the following data for the immediately preceding
July 1 to June 30 reporting period for each commercial product and medical assistance
managed care product type:
new text end

new text begin (1) the number of prior authorization requests for which an authorization was issued;
and
new text end

new text begin (2) the number of prior authorization requests for which an adverse determination was
issued, broken out by health care service; by physician specialty type or type of attending
health care professional seeking prior authorization; by whether the adverse determination
was appealed; and by whether the adverse determination was upheld or reversed on appeal.
new text end

new text begin (b) All information posted under this section must be written in easily understandable
language.
new text end

Sec. 24.

Minnesota Statutes 2018, section 256B.0625, subdivision 25, is amended to read:

Subd. 25.

Prior authorization required.

(a) The commissioner shall publish in the
Minnesota health care programs provider manual and on the department's website a list of
health services that require prior authorization, the criteria and standards used to select
health services on the list, and the criteria and standards used to determine whether certain
providers must obtain prior authorization for their services. The list of services requiring
prior authorization and the criteria and standards used to formulate the list of services or
the selection of providers for whom prior authorization is required are not subject to the
requirements of sections 14.001 to 14.69. The commissioner's decision whether prior
authorization is required for a health service or is required for a provider is not subject to
administrative appeal. Use of criteria or standards to select providers for whom prior
authorization is required shall not impede access to the service involved for any group of
individuals with unique or special needs due to disability or functional condition.

(b) The commissioner shall implement a modernized electronic system for providers to
request prior authorization. The modernized electronic system must include at least the
following functionalities:

(1) authorizations are recipient-centric, not provider-centric;

(2) adequate flexibility to support authorizations for an episode of care, continuous drug
therapy, or for individual onetime services and allows an ordering and a rendering provider
to both submit information into one request;

(3) allows providers to review previous authorization requests and determine where a
submitted request is within the authorization process;

(4) supports automated workflows that allow providers to securely submit medical
information that can be accessed by medical and pharmacy review vendors as well as
department staff; and

(5) supports development of automated clinical algorithms that can verify information
and provide responses in real time.

(c) The system described in paragraph (b) shall be completed by March 1, 2012. All
authorization requests submitted on and after March 1, 2012, or upon completion of the
modernized authorization system, whichever is later, must be submitted electronically by
providers, except requests for drugs dispensed by an outpatient pharmacy, services that are
provided outside of the state and surrounding local trade area, and services included on a
service agreement.

new text begin (d) The commissioner shall comply with the requirements for prior authorization in
chapter 62M, when implementing prior authorization under this chapter.
new text end

Sec. 25. new text begin DEVELOPMENT OF ELECTRONIC PRIOR AUTHORIZATION FORM.
new text end

new text begin (a) The commissioner of health shall develop a uniform electronic prior authorization
form for use by utilization review organizations and attending health care professionals. In
developing the form, the commissioner shall:
new text end

new text begin (1) obtain input from interested parties, including psychiatrists, physicians, health plan
companies, and utilization review organizations; and
new text end

new text begin (2) take into consideration existing prior authorization forms established by the federal
Centers for Medicare and Medicaid Services or the commissioner, and national standards
relating to electronic prior authorization.
new text end

new text begin (b) The uniform electronic prior authorization form required by this section must be
developed and available for use by utilization review organizations and attending health
care professionals by January 1, 2022.
new text end

Sec. 26. new text begin SEVERABILITY.
new text end

new text begin If any provision of this act is held invalid, illegal, or unenforceable, the remaining
provisions of this act are valid.
new text end

Sec. 27. new text begin REPEALER.
new text end

new text begin Minnesota Statutes 2018, sections 62D.12, subdivision 19; 62M.02, subdivision 19;
62M.05, subdivision 3b; and 62M.06, subdivision 2, new text end new text begin are repealed.
new text end

ARTICLE 2

CONFORMING CHANGES

Section 1.

Minnesota Statutes 2018, section 62M.02, subdivision 2, is amended to read:

Subd. 2.

Appeal.

"Appeal" means a formal request, either orally or in writing, to
reconsider deleted text begin a deleted text end new text begin an adverse new text end determination deleted text begin not to certify deleted text end new text begin regarding new text end an admission, extension of
stay, or other health care service.

Sec. 2.

Minnesota Statutes 2018, section 62M.04, subdivision 1, is amended to read:

Subdivision 1.

Responsibility for obtaining deleted text begin certification deleted text end new text begin authorization new text end .

A health
benefit plan that includes utilization review requirements must specify the process for
notifying the utilization review organization in a timely manner and obtaining deleted text begin certification deleted text end new text begin
authorization new text end for health care services. Each health plan company must provide a clear and
concise description of this process to an enrollee as part of the policy, subscriber contract,
or certificate of coverage. In addition to the enrollee, the utilization review organization
must allow any provider or provider's designee, or responsible patient representative,
including a family member, to fulfill the obligations under the health plan.

A claims administrator that contracts directly with providers for the provision of health
care services to enrollees may, through contract, require the provider to notify the review
organization in a timely manner and obtain deleted text begin certification deleted text end new text begin authorization new text end for health care services.

Sec. 3.

Minnesota Statutes 2018, section 62M.04, subdivision 2, is amended to read:

Subd. 2.

Information upon which utilization review is conducted.

(a) If the utilization
review organization is conducting routine prospective and concurrent utilization review,
utilization review organizations must collect only the information necessary to deleted text begin certify deleted text end new text begin
authorize new text end the admission, procedure of treatment, and length of stay.

(b) Utilization review organizations may request, but may not require providers to supply new text begin , new text end
numerically encoded diagnoses or procedures as part of the deleted text begin certification deleted text end new text begin authorization new text end
process.

(c) Utilization review organizations must not routinely request copies of medical records
for all patients reviewed. In performing prospective and concurrent review, copies of the
pertinent portion of the medical record should be required only when a difficulty develops
in deleted text begin certifying deleted text end new text begin authorizing new text end the medical necessity or appropriateness of the admission or
extension of stay.

(d) Utilization review organizations may request copies of medical records retrospectively
for a number of purposes, including auditing the services provided, quality assurance review,
ensuring compliance with the terms of either the health benefit plan or the provider contract,
and compliance with utilization review activities. Except for reviewing medical records
associated with an appeal or with an investigation or audit of data discrepancies, providers
must be reimbursed for the reasonable costs of duplicating records requested by the utilization
review organization for retrospective review unless otherwise provided under the terms of
the provider contract.

Sec. 4.

Minnesota Statutes 2018, section 62M.04, subdivision 3, is amended to read:

Subd. 3.

Data elements.

(a) Except as otherwise provided in deleted text begin sections 62M.01 to 62M.16 deleted text end new text begin
this chapter new text end , for purposes of deleted text begin certification deleted text end new text begin authorization new text end a utilization review organization
must limit its data requirements to the following elements:

(b) Patient information that includes the following:

(1) name;

(2) address;

(3) date of birth;

(4) sex;

(5) Social Security number or patient identification number;

(6) name of health plan company or health plan; and

(7) plan identification number.

(c) Enrollee information that includes the following:

(1) name;

(2) address;

(3) Social Security number or employee identification number;

(4) relation to patient;

(5) employer;

(6) health benefit plan;

(7) group number or plan identification number; and

(8) availability of other coverage.

(d) Attending health care professional information that includes the following:

(1) name;

(2) address;

(3) telephone numbers;

(4) degree and license;

(5) specialty or board certification status; and

(6) tax identification number or other identification number.

(e) Diagnosis and treatment information that includes the following:

(1) primary diagnosis with associated ICD or DSM coding, if available;

(2) secondary diagnosis with associated ICD or DSM coding, if available;

(3) tertiary diagnoses with associated ICD or DSM coding, if available;

(4) proposed procedures or treatments with ICD or associated CPT codes, if available;

(5) surgical assistant requirement;

(6) anesthesia requirement;

(7) proposed admission or service dates;

(8) proposed procedure date; and

(9) proposed length of stay.

(f) Clinical information that includes the following:

(1) support and documentation of appropriateness and level of service proposed; and

(2) identification of contact person for detailed clinical information.

(g) Facility information that includes the following:

(1) type;

(2) licensure and certification status and DRG exempt status;

(3) name;

(4) address;

(5) telephone number; and

(6) tax identification number or other identification number.

(h) Concurrent or continued stay review information that includes the following:

(1) additional days, services, or procedures proposed;

(2) reasons for extension, including clinical information sufficient for support of
appropriateness and level of service proposed; and

(3) diagnosis status.

(i) For admissions to facilities other than acute medical or surgical hospitals, additional
information that includes the following:

(1) history of present illness;

(2) patient treatment plan and goals;

(3) prognosis;

(4) staff qualifications; and

(5) 24-hour availability of staff.

Additional information may be required for other specific review functions such as
discharge planning or catastrophic case management. Second opinion information may also
be required, when applicable, to support benefit plan requirements.

Sec. 5.

Minnesota Statutes 2018, section 62M.05, subdivision 3, is amended to read:

Subd. 3.

Notification of new text begin adverse new text end determinations new text begin and authorizations new text end .

A utilization
review organization must have written procedures for providing notification of deleted text begin its
determinations on deleted text end all deleted text begin certifications deleted text end new text begin of its adverse determinations and authorizations new text end in
accordance with this section.

Sec. 6.

Minnesota Statutes 2018, section 62M.05, subdivision 5, is amended to read:

Subd. 5.

Notification to claims administrator.

If the utilization review organization
and the claims administrator are separate entities, the utilization review organization must
forward, electronically or in writing, a notification of deleted text begin certification or determination not to
certify deleted text end new text begin an authorization or adverse determination new text end to the appropriate claims administrator
for the health benefit plan. If it is determined by the claims administrator that the deleted text begin certified deleted text end new text begin
authorized new text end health care service is not covered by the health benefit plan, the claims
administrator must promptly notify the claimant and provider of this information.

Sec. 7.

Minnesota Statutes 2018, section 62M.06, subdivision 1, is amended to read:

Subdivision 1.

Procedures for appeal.

(a) A utilization review organization must have
written procedures for appeals of new text begin adverse new text end determinations deleted text begin not to certify deleted text end . The right to appeal
must be available to the enrollee and to the attending health care professional.

(b) The enrollee shall be allowed to review the information relied upon in the course of
the appeal, present evidence and testimony as part of the appeals process, and receive
continued coverage pending the outcome of the appeals process. This paragraph does not
apply to managed care plans or county-based purchasing plans serving state public health
care program enrollees under section 256B.69, 256B.692, or chapter 256L, or to
grandfathered plans as defined under section 62A.011, subdivision 1c. Nothing in this
paragraph shall be construed to limit or restrict the appeal rights of state public health care
program enrollees provided under section 256.045 and Code of Federal Regulations, title
42, section 438.420(d).

Sec. 8.

Minnesota Statutes 2018, section 62M.06, subdivision 4, is amended to read:

Subd. 4.

Notification to claims administrator.

If the utilization review organization
and the claims administrator are separate entities, the utilization review organization must
notify, either electronically or in writing, the appropriate claims administrator for the health
benefit plan of any new text begin adverse new text end determination deleted text begin not to certify deleted text end that is reversed on appeal.

Sec. 9.

Minnesota Statutes 2018, section 62M.09, subdivision 3a, is amended to read:

Subd. 3a.

Mental health and substance abuse reviews.

(a) A peer of the treating mental
health or substance abuse provider, a doctoral-level psychologist, or a physician must review
requests for outpatient services in which the utilization review organization has concluded
that deleted text begin a deleted text end new text begin an adverse new text end determination deleted text begin not to certify deleted text end new text begin for new text end a mental health or substance abuse service
for clinical reasons is appropriate, provided that any final new text begin adverse new text end determination deleted text begin not to
certify deleted text end new text begin issued under section 62M.05 for a new text end treatment is made by a psychiatrist certified by
the American Board of Psychiatry and Neurology and appropriately licensed in this state
or by a doctoral-level psychologist licensed in this state.

(b) Notwithstanding paragraph (a), a doctoral-level psychologist shall not review any
request or final new text begin adverse new text end determination deleted text begin not to certify deleted text end new text begin for new text end a mental health or substance abuse
service or treatment if the treating provider is a psychiatrist.

(c) Notwithstanding the notification requirements of section 62M.05, a utilization review
organization that has made deleted text begin an initial decision deleted text end new text begin a determination new text end to deleted text begin certify deleted text end new text begin authorize new text end in
accordance with the requirements of section 62M.05 may elect to provide notification of a
determination to continue coverage through facsimile or mail.

(d) This subdivision does not apply to determinations made in connection with policies
issued by a health plan company that is assessed less than three percent of the total amount
assessed by the Minnesota Comprehensive Health Association.

Sec. 10.

Minnesota Statutes 2018, section 62M.09, subdivision 4, is amended to read:

Subd. 4.

Dentist plan reviews.

A dentist must review all cases in which the utilization
review organization has concluded that deleted text begin a deleted text end new text begin an adverse new text end determination deleted text begin not to certify deleted text end new text begin for new text end a dental
service or procedure for clinical reasons is appropriate and an appeal has been made by the
attending dentist, enrollee, or designee.

Sec. 11.

Minnesota Statutes 2018, section 62M.09, subdivision 4a, is amended to read:

Subd. 4a.

Chiropractic review.

A chiropractor must review all cases in which the
utilization review organization has concluded that deleted text begin a deleted text end new text begin an adverse new text end determination deleted text begin not to certify deleted text end new text begin
for new text end a chiropractic service or procedure for clinical reasons is appropriate and an appeal has
been made by the attending chiropractor, enrollee, or designee.

Sec. 12.

Minnesota Statutes 2018, section 62M.09, subdivision 5, is amended to read:

Subd. 5.

Written clinical criteria.

A utilization review organization's decisions must
be supported by written clinical criteria and review procedures. Clinical criteria and review
procedures must be established with appropriate involvement from actively practicing
physicians. A utilization review organization must use written clinical criteria, as required,
for determining the appropriateness of the deleted text begin certification deleted text end new text begin authorization new text end request. The utilization
review organization must have a procedure for ensuring, at a minimum, the annual evaluation
and updating of the written criteria based on sound clinical principles.

Sec. 13.

Minnesota Statutes 2018, section 62M.12, is amended to read:

62M.12 PROHIBITION OF INAPPROPRIATE INCENTIVES.

No individual who is performing utilization review may receive any financial incentive
based on the number of deleted text begin denials of certifications deleted text end new text begin adverse determinations new text end made by such
individual, provided that utilization review organizations may establish medically appropriate
performance standards. This prohibition does not apply to financial incentives established
between health plan companies and providers.

Sec. 14.

Minnesota Statutes 2018, section 62Q.71, is amended to read:

62Q.71 NOTICE TO ENROLLEES.

Each health plan company shall provide to enrollees a clear and concise description of
its complaint resolution procedure, if applicable under section 62Q.68, subdivision 1, and
the procedure used for utilization review as defined under chapter 62M as part of the member
handbook, subscriber contract, or certificate of coverage. If the health plan company does
not issue a member handbook, the health plan company may provide the description in
another written document. The description must specifically inform enrollees:

(1) how to submit a complaint to the health plan company;

(2) if the health plan includes utilization review requirements, how to notify the utilization
review organization in a timely manner and how to obtain deleted text begin certification deleted text end new text begin authorization new text end for
health care services;

(3) how to request an appeal either through the procedures described in section 62Q.70,
if applicable, or through the procedures described in chapter 62M;

(4) of the right to file a complaint with either the commissioner of health or commerce
at any time during the complaint and appeal process;

(5) of the toll-free telephone number of the appropriate commissioner; and

(6) of the right, for individual and group coverage, to obtain an external review under
section 62Q.73 and a description of when and how that right may be exercised, including
that under most circumstances an enrollee must exhaust the internal complaint or appeal
process prior to external review. However, an enrollee may proceed to external review
without exhausting the internal complaint or appeal process under the following
circumstances:

(i) the health plan company waives the exhaustion requirement;

(ii) the health plan company is considered to have waived the exhaustion requirement
by failing to substantially comply with any requirements including, but not limited to, time
limits for internal complaints or appeals; or

(iii) the enrollee has applied for an expedited external review at the same time the enrollee
deleted text begin qualifies for and deleted text end has applied for deleted text begin an expedited deleted text end internal review under chapter 62M.

Sec. 15.

Minnesota Statutes 2018, section 62Q.73, subdivision 1, is amended to read:

Subdivision 1.

Definition.

For purposes of this section, "adverse determination" means:

(1) for individual health plans, a complaint decision relating to a health care service or
claim that is partially or wholly adverse to the complainant;

(2) an individual health plan that is grandfathered plan coverage may instead apply the
definition of adverse determination for group coverage in clause (3);

(3) for group health plans, a complaint decision relating to a health care service or claim
that has been appealed in accordance with section 62Q.70 and the appeal decision is partially
or wholly adverse to the complainant;

(4) any deleted text begin initial deleted text end new text begin adverse new text end determination deleted text begin not to certify deleted text end new text begin , as defined in section 62M.02,
subdivision 1a, new text end that has been appealed in accordance with section 62M.06 and the appeal
did not reverse the deleted text begin initial deleted text end new text begin adverse new text end determination deleted text begin not to certify deleted text end ;

(5) a decision relating to a health care service made by a health plan company licensed
under chapter 60A that denies the service on the basis that the service was not medically
necessary; or

(6) the enrollee has met the requirements of subdivision 6, paragraph (e).

An adverse determination does not include complaints relating to fraudulent marketing
practices or agent misrepresentation.

Sec. 16. new text begin REVISOR INSTRUCTIONS.
new text end

new text begin (a) In Minnesota Statutes, chapter 62M, the revisor of statutes shall replace references
to "sections 62M.01 to 62M.16" with "this chapter." In Minnesota Statutes, section 256B.692,
subdivision 2, the revisor of statutes shall replace a reference to "sections 62M.01 to 62M.16"
with "chapter 62M." The revisor shall make any necessary technical and conforming changes
to sentence structure to preserve the meaning of the text.
new text end

new text begin (b) The revisor of statutes shall replace the term "DETERMINATIONS NOT TO
CERTIFY" with "ADVERSE DETERMINATIONS" in the section headnote for Minnesota
Statutes, section 62M.06.
new text end

APPENDIX

Repealed Minnesota Statutes: 20-6464

62D.12 PROHIBITED PRACTICES.

Subd. 19.

Coverage of service.

A health maintenance organization may not deny or limit coverage of a service which the enrollee has already received solely on the basis of lack of prior authorization or second opinion, to the extent that the service would otherwise have been covered under the member's contract by the health maintenance organization had prior authorization or second opinion been obtained.

62M.02 DEFINITIONS.

Subd. 19.

Reconsideration request.

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

62M.05 PROCEDURES FOR REVIEW DETERMINATION.

Subd. 3b.

Expedited review determination.

(a) An expedited initial determination must be utilized if the attending health care professional believes that an expedited determination is warranted.

(b) Notification of an expedited initial determination to either certify or not to certify must be provided to the hospital, the attending health care professional, and the enrollee as expeditiously as the enrollee's medical condition requires, but no later than 72 hours from the initial request. When an expedited initial determination is made not to certify, the utilization review organization must also notify the enrollee and the attending health care professional of the right to submit an appeal to the expedited internal appeal as described in section 62M.06 and the procedure for initiating an internal expedited appeal.

62M.06 APPEALS OF DETERMINATIONS NOT TO CERTIFY.

Subd. 2.

Expedited appeal.

(a) When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review and the attending health care professional believes that the determination warrants an expedited appeal, the utilization review organization must ensure that the enrollee and the attending health care professional have an opportunity to appeal the determination over the telephone on an expedited basis. In such an appeal, the utilization review organization must ensure reasonable access to its consulting physician or health care provider.

(b) The utilization review organization shall notify the enrollee and attending health care professional by telephone of its determination on the expedited appeal as expeditiously as the enrollee's medical condition requires, but no later than 72 hours after receiving the expedited appeal.

(c) If the determination not to certify is not reversed through the expedited appeal, the utilization review organization must include in its notification the right to submit the appeal to the external appeal process described in section 62Q.73 and the procedure for initiating the process. This information must be provided in writing to the enrollee and the attending health care professional as soon as practical.