Minnesota Session Laws - 1992, Regular Session

  

                         Laws of Minnesota 1992 

                        CHAPTER 574-S.F.No. 651 
           An act relating to insurance; regulating utilization 
          review services; providing standards and procedures; 
          regulating appeals of determinations not to certify; 
          regulating prior authorization of services; 
          prescribing staff and program qualifications; 
          proposing coding for new law as Minnesota Statutes, 
          chapter 62M. 
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
    Section 1.  [62M.01] [CITATION, JURISDICTION, AND SCOPE.] 
    Subdivision 1.  [POPULAR NAME.] Sections 1 to 16 may be 
cited as the "Minnesota utilization review act of 1992." 
    Subd. 2.  [JURISDICTION.] Sections 1 to 16 apply 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; 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 2; or any entity performing utilization 
review on behalf of a business entity in this state pursuant to 
a health benefit plan covering a Minnesota resident. 
    Subd. 3.  [SCOPE.] Sections 2, 7, and 9, subdivision 4, 
apply to prior authorization of services.  Nothing in sections 1 
to 16 applies to review of claims after submission to determine 
eligibility for benefits under a health benefit plan.  
    Sec. 2.  [62M.02] [DEFINITIONS.] 
    Subdivision 1.  [TERMS.] For the purposes of sections 1 to 
16, the terms defined in this section have the meanings given 
them. 
    Subd. 2.  [APPEAL.] "Appeal" means a formal request, either 
orally or in writing, to reconsider a determination not to 
certify an admission, extension of stay, or other health care 
service. 
    Subd. 3.  [ATTENDING DENTIST.] "Attending dentist" means 
the dentist with primary responsibility for the dental care 
provided to a patient. 
    Subd. 4.  [ATTENDING PHYSICIAN.] "Attending physician" 
means the physician with primary responsibility for the care 
provided to a patient in a hospital or other health care 
facility. 
    Subd. 5.  [CERTIFICATION.] "Certification" means a 
determination by a utilization review organization that an 
admission, extension of stay, or other health care service has 
been reviewed and that it, based on the information provided, 
meets the utilization review requirements of the applicable 
health plan. 
    Subd. 6.  [CLAIMS ADMINISTRATOR.] "Claims administrator" 
means an entity that reviews and determines whether to pay 
claims to enrollees, physicians, hospitals, or others based on 
the contract provisions of the health plan contract.  Claims 
administrators may include insurance companies 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; a fraternal benefit 
society operating under chapter 64B; 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. 
    Subd. 7.  [CLAIMANT.] "Claimant" means the enrollee or 
covered person who files a claim for benefits or a provider of 
services who, pursuant to a contract with a claims 
administrator, files a claim on behalf of an enrollee or covered 
person. 
    Subd. 8.  [CLINICAL CRITERIA.] "Clinical criteria" means 
the written policies, decision rules, medical protocols, or 
guidelines used by the utilization review organization to 
determine certification. 
    Subd. 9.  [CONCURRENT REVIEW.] "Concurrent review" means 
utilization review conducted during a patient's hospital stay or 
course of treatment and has the same meaning as continued stay 
review. 
    Subd. 10.  [DISCHARGE PLANNING.] "Discharge planning" means 
the process that assesses a patient's need for treatment after 
hospitalization in order to help arrange for the necessary 
services and resources to effect an appropriate and timely 
discharge. 
    Subd. 11.  [ENROLLEE.] "Enrollee" means an individual who 
has elected to contract for, or participate in, a health benefit 
plan for enrollee coverage or for dependent coverage. 
    Subd. 12.  [HEALTH BENEFIT PLAN.] "Health benefit plan" 
means a policy, contract, or certificate issued by a health 
carrier to an employer or individual for the coverage of 
medical, dental, or hospital benefits.  A health benefit plan 
does not include coverage that is: 
    (1) limited to disability or income protection coverage; 
    (2) automobile medical payment coverage; 
    (3) supplemental to liability insurance; 
    (4) designed solely to provide payments on a per diem, 
fixed indemnity, or nonexpense incurred basis; 
    (5) credit accident and health insurance issued under 
chapter 62B; 
    (6) blanket accident and sickness insurance as defined in 
section 62A.11; 
    (7) accident only coverage issued by a licensed and tested 
insurance agent; or 
    (8) workers' compensation. 
    Subd. 13.  [INPATIENT ADMISSIONS TO HOSPITALS.] "Inpatient 
admissions to hospitals" includes admissions to all acute 
medical, surgical, obstetrical, psychiatric, and chemical 
dependency inpatient services at a licensed hospital facility, 
as well as other licensed inpatient facilities including skilled 
nursing facilities, residential treatment centers, and free 
standing rehabilitation facilities. 
    Subd. 14.  [OUTPATIENT SERVICES.] "Outpatient services" 
means procedures or services performed on a basis other than as 
an inpatient, and includes obstetrical, psychiatric, chemical 
dependency, dental, and chiropractic services. 
    Subd. 15.  [PRIOR AUTHORIZATION.] "Prior authorization" 
means utilization review conducted prior to the delivery of a 
service, including an outpatient service. 
    Subd. 16.  [PROSPECTIVE REVIEW.] "Prospective review" means 
utilization review conducted prior to an enrollee's inpatient 
stay. 
    Subd. 17.  [PROVIDER.] "Provider" means a licensed health 
care facility, physician, or other health care professional that 
delivers health care services to an enrollee or covered person. 
    Subd. 18.  [QUALITY ASSESSMENT PROGRAM.] "Quality 
assessment program" means a structured mechanism that monitors 
and evaluates a utilization review organization's program and 
provides management intervention to support compliance with the 
requirements of this chapter. 
    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. 
    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 physician, for 
the purpose of determining the medical necessity of the service 
or admission.  Utilization review also includes 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 the 
imposition of a requirement that services be received by or upon 
referral from a participating provider. 
    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 health service plan licensed under 
chapter 62C; a health maintenance organization licensed under 
chapter 62D; 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 
determines certification of an admission, extension of stay, or 
other health care services for a Minnesota resident; or any 
entity performing utilization review that is affiliated with, 
under contract with, or conducting utilization review on behalf 
of, a business entity in this state. 
    Sec. 3.  [62M.03] [COMPLIANCE WITH STANDARDS.] 
    Subdivision 1.  [LICENSED UTILIZATION REVIEW ORGANIZATION.] 
Beginning January 1, 1993, any organization that is licensed in 
this state and that meets the definition of utilization review 
organization in section 2, subdivision 21, must comply with 
sections 1 to 16. 
    Subd. 2.  [NONLICENSED UTILIZATION REVIEW ORGANIZATION.] An 
organization that meets the definition of a utilization review 
organization under section 2, subdivision 21, that is not 
licensed in this state that performs utilization review services 
for Minnesota residents must register with the commissioner of 
commerce and must certify compliance with sections 1 to 16. 
    Initial registration must occur no later than January 1, 
1993. 
    Subd. 3.  [PENALTIES AND ENFORCEMENTS.] If a nonlicensed 
utilization review organization fails to comply with sections 1 
to 16, the organization may not provide utilization review 
services for any Minnesota resident.  The commissioner of 
commerce may issue a cease and desist order under section 
45.027, subdivision 5, to enforce this provision.  The cease and 
desist order is subject to appeal under chapter 14.  A 
nonlicensed utilization review organization that fails to comply 
with the provisions of sections 1 to 16 is subject to all 
applicable penalty and enforcement provisions of section 72A.201.
    Sec. 4.  [62M.04] [STANDARDS FOR UTILIZATION REVIEW 
PERFORMANCE.] 
    Subdivision 1.  [RESPONSIBILITY FOR OBTAINING 
CERTIFICATION.] 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 
certification for health care services.  In addition to the 
enrollee, the utilization review organization must allow any 
licensed hospital, physician or the physician'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 certification for 
health care services. 
    Subd. 2.  [INFORMATION UPON WHICH UTILIZATION REVIEW IS 
CONDUCTED.] If the utilization review organization is conducting 
routine prospective and concurrent utilization review, 
utilization review organizations must collect only the 
information necessary to certify the admission, procedure of 
treatment, and length of stay. 
    (a) Utilization review organizations may request, but may 
not require, hospitals, physicians, or other providers to supply 
numerically encoded diagnoses or procedures as part of the 
certification process. 
    (b) 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 certifying the medical necessity 
or appropriateness of the admission or extension of stay. 
    (c) 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, health care 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. 
    Subd. 3.  [DATA ELEMENTS.] Except as otherwise provided in 
sections 1 to 16, for purposes of certification a utilization 
review organization must limit its data requirements to the 
following elements: 
    (a) 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 carrier or health plan; and 
    (7) plan identification number. 
    (b) 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. 
    (c) Attending physician or provider 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. 
    (d) 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. 
    (e) 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. 
    (f) 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. 
    (g) 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. 
    (h) 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. 
    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 
health care provider regarding the appropriateness of 
certification 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 certified; 
    (2) referred the case to a physician for review; and 
    (3) talked to or attempted to talk to the attending 
physician for further information. 
    Nothing in sections 1 to 16 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. 
    Subd. 5.  [SHARING OF INFORMATION.] To the extent allowed 
under sections 72A.49 to 72A.505, a utilization review 
organization shall share all available clinical and demographic 
information on individual patients internally to avoid duplicate 
requests for information from enrollees or providers. 
    Sec. 5.  [62M.05] [PROCEDURES FOR REVIEW DETERMINATION.] 
    Subdivision 1.  [WRITTEN PROCEDURES.] A utilization review 
organization must have written procedures to ensure that reviews 
are conducted in accordance with the requirements of this 
chapter and section 72A.20, subdivision 4a. 
    Subd. 2.  [CONCURRENT REVIEW.] A utilization review 
organization may review ongoing inpatient stays based on the 
severity or complexity of the patient's condition or on 
necessary treatment or discharge planning activities.  Such 
review must not be consistently conducted on a daily basis. 
     Subd. 3.  [NOTIFICATION OF DETERMINATIONS.] A utilization 
review organization must have written procedures for providing 
notification of its determinations on all certifications in 
accordance with the following: 
     (a) When an initial determination is made to certify, 
notification must be provided promptly by telephone to the 
provider. 
    (b) When a determination is made not to certify a hospital 
or surgical facility admission or extension of a hospital stay, 
or other service requiring review determination, within one 
working day after making the decision the attending physician 
and hospital must be notified by telephone and a written 
notification must be sent to the hospital, attending physician, 
and enrollee or patient.  The written notification must include 
the principal reason or reasons for the determination and the 
process for initiating an appeal of the determination.  Reasons 
for a determination not to certify may include, among other 
things, the lack of adequate information to certify after a 
reasonable attempt has been made to contact the attending 
physician. 
    Subd. 4.  [FAILURE TO PROVIDE NECESSARY INFORMATION.] A 
utilization review organization must have written procedures to 
address the failure of a health care provider, patient, or 
representative of either to provide the necessary information 
for review.  If the patient or provider will not release the 
necessary information to the utilization review organization, 
the utilization review organization may deny certification in 
accordance with its own policy or the policy described in the 
health benefit plan. 
    Sec. 6.  [62M.06] [APPEALS OF DETERMINATIONS NOT TO 
CERTIFY.] 
    Subdivision 1.  [PROCEDURES FOR APPEAL.] A utilization 
review organization must have written procedures for appeals of 
determinations not to certify an admission, procedure, service, 
or extension of stay.  The right to appeal must be available to 
the enrollee or designee and to the attending physician.  The 
right of appeal must be communicated to the enrollee or designee 
or to the attending physician, whomever initiated the original 
certification request, at the time that the original 
determination is communicated. 
     Subd. 2.  [EXPEDITED APPEAL.] 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 physician 
believes that the determination warrants immediate appeal, the 
utilization review organization must ensure that the attending 
physician, enrollee, or designee has 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.  Expedited 
appeals that are not resolved may be resubmitted through the 
standard appeal process. 
    Subd. 3.  [STANDARD APPEAL.] The utilization review 
organization must establish procedures for appeals to be made 
either in writing or by telephone. 
    (a) Each utilization review organization shall notify in 
writing the enrollee or patient, attending physician, and claims 
administrator of its determination on the appeal as soon as 
practical, but in no case later than 45 days after receiving the 
required documentation on the appeal. 
    (b) 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 health care provider. 
    (c) Prior to upholding the original decision not to certify 
for clinical reasons, the utilization review organization shall 
conduct a review of the documentation by a physician who did not 
make the original determination not to certify. 
    (d) 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 patient, enrollee, or attending physician 
when the initial determination is made. 
    (e) An attending physician who has been unsuccessful in an 
attempt to reverse a determination not to certify 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. 
    (f) In cases where an appeal to reverse a determination not 
to certify for clinical reasons is unsuccessful, the utilization 
review organization must ensure that a physician in the same or 
a similar general specialty as typically manages the medical 
condition, procedure, or treatment under discussion is 
reasonably available to review the case. 
     Subd. 4.  [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 
certification or determination not to certify to the appropriate 
claims administrator for the health benefit plan.  
    Sec. 7.  [62M.07] [PRIOR AUTHORIZATION OF SERVICES.] 
    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 72A.20, subdivision 4a, 
regarding time frames for approving and disapproving prior 
authorization requests; 
    (4) written procedures for appeals of denials of prior 
authorization which specify the responsibilities of the enrollee 
and provider, and which meet the requirements of section 
72A.285, regarding release of summary review findings; and 
    (5) procedures to ensure confidentiality of 
patient-specific information, consistent with applicable law. 
    Sec. 8.  [62M.08] [CONFIDENTIALITY.] 
    Subdivision 1.  [WRITTEN PROCEDURES TO ENSURE 
CONFIDENTIALITY.] A utilization review organization must have 
written procedures for ensuring that patient-specific 
information obtained during the process of utilization review 
will be: 
    (1) kept confidential in accordance with applicable federal 
and state laws; 
    (2) used solely for the purposes of utilization review, 
quality assurance, discharge planning, and case management; and 
    (3) shared only with those organizations or persons that 
have the authority to receive such information. 
    Subd. 2.  [SUMMARY DATA.] Summary data is not subject to 
this section if it does not provide sufficient information to 
allow identification of individual patients. 
    Sec. 9.  [62M.09] [STAFF AND PROGRAM QUALIFICATIONS.] 
    Subdivision 1.  [STAFF CRITERIA.] A utilization review 
organization shall have utilization review staff who are 
properly trained, qualified, and supervised. 
    Subd. 2.  [LICENSURE REQUIREMENT.] Nurses, physicians, and 
other licensed health professionals conducting reviews of 
medical services, and other clinical reviewers conducting 
specialized reviews in their area of specialty must be currently 
licensed or certified by an approved state licensing agency in 
the United States. 
    Subd. 3.  [PHYSICIAN REVIEWER INVOLVEMENT.] A physician 
must review all cases in which the utilization review 
organization has concluded that a determination not to certify 
for clinical reasons is appropriate.  The physician should be 
reasonably available by telephone to discuss the determination 
with the attending physician. 
    Subd. 4.  [DENTIST PLAN REVIEWS.] A dentist must review all 
cases in which the utilization review organization has concluded 
that a determination not to certify a dental service or 
procedure for clinical reasons is appropriate and an appeal has 
been made by the attending dentist, enrollee, or designee. 
    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 
physicians.  A utilization review organization must use written 
clinical criteria, as required, for determining the 
appropriateness of the certification request.  The utilization 
review organization must have a procedure for ensuring the 
periodic evaluation and updating of the written criteria. 
    Subd. 6.  [PHYSICIAN CONSULTANTS.] A utilization review 
organization must use physician consultants in the appeal 
process described in section 6, subdivision 3.  The physician 
consultants should include, as needed and available, specialists 
who are board-certified, or board-eligible and working towards 
certification, in a specialty board approved by the American 
Board of Medical Specialists or the American Board of Osteopathy.
    Subd. 7.  [TRAINING FOR PROGRAM STAFF.] A utilization 
review organization must have a formalized program of 
orientation and ongoing training of utilization review staff. 
    Subd. 8.  [QUALITY ASSESSMENT PROGRAM.] A utilization 
review organization must have written documentation of an active 
quality assessment program. 
    Sec. 10.  [62M.10] [ACCESSIBILITY AND ON-SITE REVIEW 
PROCEDURES.] 
    Subdivision 1.  [TOLL-FREE NUMBER.] A utilization review 
organization must provide access to its review staff by a 
toll-free or collect call telephone line during normal business 
hours.  A utilization review organization must also have an 
established procedure to receive timely callbacks from providers 
and must establish written procedures for receiving after-hour 
calls, either in person or by recording. 
    Subd. 2.  [REVIEWS DURING NORMAL BUSINESS HOURS.] A 
utilization review organization must conduct its telephone 
reviews, on-site reviews, and hospital communications during 
hospitals' and physicians' reasonable and normal business hours, 
unless otherwise mutually agreed. 
    Subd. 3.  [IDENTIFICATION OF ON-SITE REVIEW STAFF.] Each 
utilization review organization's staff must identify themselves 
by name and by the name of their organization and, for on-site 
reviews, must carry picture identification and the utilization 
review organization's company identification card.  On-site 
reviews should, whenever possible, be scheduled at least one 
business day in advance with the appropriate hospital contact.  
If requested by a hospital or inpatient facility, utilization 
review organizations must ensure that their on-site review staff 
register with the appropriate contact person, if available, 
prior to requesting any clinical information or assistance from 
hospital staff.  The on-site review staff must wear appropriate 
hospital supplied identification tags while on the premises. 
    Subd. 4.  [ON-SITE REVIEWS.] Utilization review 
organizations must agree, if requested, that the medical records 
remain available in designated areas during the on-site review 
and that reasonable hospital administrative procedures must be 
followed by on-site review staff so as to not disrupt hospital 
operations or patient care.  Such procedures, however, must not 
limit the ability of the utilization review organizations to 
efficiently conduct the necessary review on behalf of the 
patient's health benefit plan. 
    Subd. 5.  [ORAL REQUESTS FOR INFORMATION.] Utilization 
review organizations shall orally inform, upon request, 
designated hospital personnel or the attending physician of the 
utilization review requirements of the specific health benefit 
plan and the general type of criteria used by the review agent.  
Utilization review organizations should also orally inform, upon 
request, hospitals, physicians, and other health care 
professionals of the operational procedures in order to 
facilitate the review process. 
    Subd. 6.  [MUTUAL AGREEMENT.] Nothing in this section 
limits the ability of a utilization review organization and a 
provider to mutually agree in writing on how review should be 
conducted. 
    Sec. 11.  [62M.11] [COMPLAINTS TO COMMERCE OR HEALTH.] 
    Notwithstanding the provisions of sections 1 to 16, an 
enrollee may file a complaint regarding a determination not to 
certify directly to the commissioner responsible for regulating 
the utilization review organization. 
    Sec. 12.  [62M.12] [PROHIBITION OF INAPPROPRIATE 
INCENTIVES.] 
    No individual who is performing utilization review may 
receive any financial incentive based on the number of denials 
of certifications 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 plans 
and their providers. 
    Sec. 13.  [62M.13] [SEVERABILITY.] 
    If any provisions of sections 1 to 16 are held invalid, 
illegal, or unenforceable for any reason and in any respect, the 
holding does not affect the validity of the remainder of 
sections 1 to 16. 
    Sec. 14.  [62M.14] [EFFECT OF COMPLIANCE.] 
    Evidence of a utilization review organization's compliance 
or noncompliance with the provisions of sections 1 to 16 shall 
not be determinative in an action alleging that services denied 
were medically necessary and covered under the terms of the 
enrollee's health benefit plan. 
    Sec. 15.  [62M.15] [APPLICABILITY OF OTHER CHAPTER 
REQUIREMENTS.] 
    The requirements of this chapter regarding the conduct of 
utilization review are in addition to any specific requirements 
contained in chapter 62A, 62C, 62D, or 72A. 
    Sec. 16.  [62M.16] [RULEMAKING.] 
    If it is determined that rules are reasonable and necessary 
to accomplish the purpose of sections 1 to 16, the rules must be 
adopted through a joint rulemaking process by both the 
department of commerce and the department of health. 
    Sec. 17.  [EFFECTIVE DATE.] 
    Sections 1 to 16 are effective January 1, 1993. 
    Presented to the governor April 17, 1992 
    Signed by the governor April 29, 1992, 10:23 a.m.