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Minnesota Legislature

Office of the Revisor of Statutes

Key: (1) language to be deleted (2) new language

                            CHAPTER 239-S.F.No. 1219 
                  An act relating to health; establishing a uniform 
                  complaint resolution process for health plan 
                  companies; establishing an external review process; 
                  amending Minnesota Statutes 1998, sections 62D.11, 
                  subdivision 1; 62M.01; 62M.02, subdivisions 3, 4, 5, 
                  6, 7, 9, 10, 11, 12, 17, 20, 21, and by adding a 
                  subdivision; 62M.03, subdivisions 1 and 3; 62M.04, 
                  subdivisions 1, 2, 3, and 4; 62M.05; 62M.06; 62M.07; 
                  62M.09, subdivision 3; 62M.10, subdivisions 2, 5, and 
                  7; 62M.12; 62M.15; 62Q.106; 62Q.19, subdivision 5a; 
                  62T.04; 72A.201, subdivision 4a; and 256B.692, 
                  subdivision 2; proposing coding for new law in 
                  Minnesota Statutes, chapters 62D; and 62Q; repealing 
                  Minnesota Statutes 1998, sections 62D.11, subdivisions 
                  1b and 2; 62Q.105; 62Q.11; and 62Q.30; Minnesota 
                  Rules, parts 4685.0100, subparts 4 and 4a; 4685.1010, 
                  subpart 3; and 4685.1700. 
        BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
           Section 1.  Minnesota Statutes 1998, section 62D.11, 
        subdivision 1, is amended to read: 
           Subdivision 1.  [ENROLLEE COMPLAINT SYSTEM.] Every health 
        maintenance organization shall establish and maintain a 
        complaint system, as required under section 62Q.105 sections 
        62Q.68 to 62Q.72 to provide reasonable procedures for the 
        resolution of written complaints initiated by or on behalf of 
        enrollees concerning the provision of health care 
        services.  "Provision of health services" includes, but is not 
        limited to, questions of the scope of coverage, quality of care, 
        and administrative operations.  The health maintenance 
        organization must inform enrollees that they may choose to use 
        arbitration to appeal a health maintenance organization's 
        internal appeal decision.  The health maintenance organization 
        must also inform enrollees that they have the right to use 
        arbitration to appeal a health maintenance organization's 
        internal appeal decision not to certify an admission, procedure, 
        service, or extension of stay under section 62M.06.  If an 
        enrollee chooses to use arbitration, the health maintenance 
        organization must participate. 
           Sec. 2.  [62D.124] [GEOGRAPHIC ACCESSIBILITY.] 
           Subdivision 1.  [PRIMARY CARE; MENTAL HEALTH SERVICES; 
        GENERAL HOSPITAL SERVICES.] Within the health maintenance 
        organization's service area, the maximum travel distance or time 
        shall be the lesser of 30 miles or 30 minutes to the nearest 
        provider of each of the following services:  primary care 
        services, mental health services, and general hospital 
        services.  The health maintenance organization must designate 
        which method is used.  
           Subd. 2.  [OTHER HEALTH SERVICES.] Within a health 
        maintenance organization's service area, the maximum travel 
        distance or time shall be the lesser of 60 miles or 60 minutes 
        to the nearest provider of specialty physician services, 
        ancillary services, specialized hospital services, and all other 
        health services not listed in subdivision 1.  The health 
        maintenance organization must designate which method is used. 
           Subd. 3.  [EXCEPTION.] The commissioner shall grant an 
        exception to the requirements of this section according to 
        Minnesota Rules, part 4685.1010, subpart 4, if the health 
        maintenance organization can demonstrate with specific data that 
        the requirement of subdivision 1 or 2 is not feasible in a 
        particular service area or part of a service area. 
           Subd. 4.  [APPLICATION.] (a) Subdivisions 1 and 2 do not 
        apply if an enrollee is referred to a referral center for health 
        care services.  
           (b) Subdivision 1 does not apply: 
           (1) if an enrollee has chosen a health plan with full 
        knowledge that the health plan has no participating providers 
        within 30 miles or 30 minutes of the enrollee's place of 
        residence; or 
           (2) to service areas approved before May 24, 1993. 
           Sec. 3.  Minnesota Statutes 1998, section 62M.01, is 
        amended to read: 
           62M.01 [CITATION, JURISDICTION, AND SCOPE.] 
           Subdivision 1.  [POPULAR NAME.] Sections 62M.01 to 62M.16 
        may be cited as the "Minnesota Utilization Review Act of 1992." 
           Subd. 2.  [JURISDICTION.] Sections 62M.01 to 62M.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 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; 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 62M.02, 62M.07, and 62M.09, 
        subdivision 4, apply to prior authorization of services.  
        Nothing in sections 62M.01 to 62M.16 applies to review of claims 
        after submission to determine eligibility for benefits under a 
        health benefit plan.  The appeal procedure described in section 
        62M.06 applies to any complaint as defined under section 62Q.68, 
        subdivision 2, that requires a medical determination in its 
        resolution.  
           Sec. 4.  Minnesota Statutes 1998, section 62M.02, 
        subdivision 3, is amended to read: 
           Subd. 3.  [ATTENDING DENTIST.] "Attending dentist" means 
        the dentist with primary responsibility for the dental care 
        provided to a patient an enrollee. 
           Sec. 5.  Minnesota Statutes 1998, section 62M.02, 
        subdivision 4, is amended to read: 
           Subd. 4.  [ATTENDING PHYSICIAN HEALTH CARE PROFESSIONAL.] 
        "Attending physician health care professional" means 
        the physician health care professional providing care within the 
        scope of their practice and with primary responsibility for the 
        care provided to a patient in a hospital or other health care 
        facility an enrollee.  Attending health care professional shall 
        include only physicians; chiropractors; dentists; mental health 
        professionals as defined in section 245.462, subdivision 18, or 
        section 245.4871, subdivision 27; podiatrists; and advanced 
        practice nurses. 
           Sec. 6.  Minnesota Statutes 1998, section 62M.02, 
        subdivision 5, is amended to read: 
           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 and the health carrier plan company will then pay 
        for the covered benefit, provided the preexisting limitation 
        provisions, the general exclusion provisions, and any 
        deductible, copayment, coinsurance, or other policy requirements 
        have been met. 
           Sec. 7.  Minnesota Statutes 1998, section 62M.02, 
        subdivision 6, is amended to read: 
           Subd. 6.  [CLAIMS ADMINISTRATOR.] "Claims administrator" 
        means an entity that reviews and determines whether to pay 
        claims to enrollees, physicians, hospitals, or others or 
        providers 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 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 
        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. 
           Sec. 8.  Minnesota Statutes 1998, section 62M.02, 
        subdivision 7, is amended to read: 
           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. 
           Sec. 9.  Minnesota Statutes 1998, section 62M.02, 
        subdivision 9, is amended to read: 
           Subd. 9.  [CONCURRENT REVIEW.] "Concurrent review" means 
        utilization review conducted during a patient's an enrollee's 
        hospital stay or course of treatment and has the same meaning as 
        continued stay review. 
           Sec. 10.  Minnesota Statutes 1998, section 62M.02, 
        subdivision 10, is amended to read: 
           Subd. 10.  [DISCHARGE PLANNING.] "Discharge planning" means 
        the process that assesses a patient's an enrollee's need for 
        treatment after hospitalization in order to help arrange for the 
        necessary services and resources to effect an appropriate and 
        timely discharge. 
           Sec. 11.  Minnesota Statutes 1998, section 62M.02, 
        subdivision 11, is amended to read: 
           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 covered by 
        a health benefit plan and includes an insured policyholder, 
        subscriber, contract holder, member, covered person, or 
        certificate holder. 
           Sec. 12.  Minnesota Statutes 1998, section 62M.02, 
        subdivision 12, is amended to read: 
           Subd. 12.  [HEALTH BENEFIT PLAN.] "Health benefit plan" 
        means a policy, contract, or certificate issued by a health 
        carrier to an employer or individual plan company 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. 
           Sec. 13.  Minnesota Statutes 1998, section 62M.02, is 
        amended by adding a subdivision to read: 
           Subd. 12a.  [HEALTH PLAN COMPANY.] "Health plan company" 
        means a health plan company as defined in section 62Q.01, 
        subdivision 4, and includes an accountable provider network 
        operating under chapter 62T. 
           Sec. 14.  Minnesota Statutes 1998, section 62M.02, 
        subdivision 17, is amended to read: 
           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. 
           Sec. 15.  Minnesota Statutes 1998, 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 physician health 
        care professional, 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 a referral or participation in a referral process by a 
        participating provider unless the provider is acting as a 
        utilization review organization. 
           Sec. 16.  Minnesota Statutes 1998, 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 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 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. 17.  Minnesota Statutes 1998, section 62M.03, 
        subdivision 1, is amended to read: 
           Subdivision 1.  [LICENSED UTILIZATION REVIEW ORGANIZATION.] 
        Beginning January 1, 1993, any organization that meets the 
        definition of utilization review organization in section 62M.02, 
        subdivision 21, must be licensed under chapter 60A, 62C, 62D, 
        62N, 62T, or 64B, or registered under this chapter and must 
        comply with sections 62M.01 to 62M.16 and section 72A.201, 
        subdivisions 8 and 8a.  Each licensed community integrated 
        service network or health maintenance organization that has an 
        employed staff model of providing health care services shall 
        comply with sections 62M.01 to 62M.16 and section 72A.201, 
        subdivisions 8 and 8a, for any services provided by providers 
        under contract. 
           Sec. 18.  Minnesota Statutes 1998, section 62M.03, 
        subdivision 3, is amended to read: 
           Subd. 3.  [PENALTIES AND ENFORCEMENTS.] If a utilization 
        review organization fails to comply with sections 62M.01 to 
        62M.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 62M.01 to 62M.16 is subject to 
        all applicable penalty and enforcement provisions of section 
        72A.201.  Each utilization review organization licensed under 
        chapter 60A, 62C, 62D, 62N, 62T, or 64B shall comply with 
        sections 62M.01 to 62M.16 as a condition of licensure. 
           Sec. 19.  Minnesota Statutes 1998, section 62M.04, 
        subdivision 1, is amended to read: 
           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.  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 
        licensed hospital, physician or the physician's 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 certification for 
        health care services. 
           Sec. 20.  Minnesota Statutes 1998, section 62M.04, 
        subdivision 2, is amended to read: 
           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. 
           Sec. 21.  Minnesota Statutes 1998, section 62M.04, 
        subdivision 3, is amended to read: 
           Subd. 3.  [DATA ELEMENTS.] Except as otherwise provided in 
        sections 62M.01 to 62M.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 plan company 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 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. 
           (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. 
           Sec. 22.  Minnesota Statutes 1998, 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 
        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 health care professional for further information. 
           Nothing in sections 62M.01 to 62M.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. 
           Sec. 23.  Minnesota Statutes 1998, section 62M.05, is 
        amended to read: 
           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.201, 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 enrollee'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: this section. 
           Subd. 3a.  [STANDARD REVIEW DETERMINATION.] (a) 
        Notwithstanding subdivision 3b, an initial determination on all 
        requests for utilization review must be communicated to the 
        provider and enrollee in accordance with this subdivision within 
        ten business days of the request, provided that all information 
        reasonably necessary to make a determination on the request has 
        been made available to the utilization review organization.  
           (b) When an initial determination is made to certify, 
        notification must be provided promptly by telephone to the 
        provider.  The utilization review organization shall send 
        written notification to the hospital, attending physician, or 
        applicable service provider within ten business days of the 
        determination in accordance with section 72A.201, subdivision 
        4a, 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 or patient; the service, 
        procedure, or admission certified; and the date of the service, 
        procedure, or admission.  If the utilization review organization 
        indicates certification by use of a number, the number must be 
        called the "certification number." 
           (b) (c) When a an initial determination is made not to 
        certify a hospital or surgical facility admission or extension 
        of a hospital stay, or other service requiring review 
        determination, notification must be provided by telephone within 
        one working day after making the decision determination to the 
        attending physician health care professional and hospital must 
        be notified by telephone and a written notification must be sent 
        to the hospital, attending physician health care professional, 
        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.  Upon 
        request, the utilization review organization shall provide 
        the attending physician or 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 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 provider or enrollee. 
           (d) When an initial determination is made not to certify, 
        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. 
           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. 
           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 or enrollee to provide the necessary 
        information for review.  If the patient enrollee 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. 
           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 
        certification or determination not to certify to the appropriate 
        claims administrator for the health benefit plan. 
           Sec. 24.  Minnesota Statutes 1998, section 62M.06, is 
        amended to read: 
           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 health 
        care professional.  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.] (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 physician health care professional believes that the 
        determination warrants immediate an expedited appeal, the 
        utilization review organization must ensure that the enrollee 
        and the attending physician, enrollee, or designee has 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.  Expedited appeals that are not resolved may be 
        resubmitted through the standard appeal process. 
           (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. 
           Subd. 3.  [STANDARD APPEAL.] The utilization review 
        organization must establish procedures for appeals to be made 
        either in writing or by telephone. 
           (a) Each A utilization review organization shall notify in 
        writing the enrollee or patient, attending physician health care 
        professional, 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 within 30 days upon receipt of the notice of appeal.  If 
        the utilization review organization cannot make a determination 
        within 30 days due to circumstances outside the control of the 
        utilization review organization, the utilization review 
        organization may take up to 14 additional days 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 30-day 
        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. 
           (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 attending health care 
        provider professional. 
           (c) Prior to upholding the original decision initial 
        determination 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 
        initial 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 and attending 
        physician health care professional when the initial 
        determination is made. 
           (e) An attending physician health care professional or 
        enrollee 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 of appeal to reverse a determination not to 
        certify for clinical reasons, the utilization review 
        organization must, upon request of the attending physician 
        health care professional, ensure that a physician of the 
        utilization review organization's choice 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. 
           (g) If the initial 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 the external process. 
           Subd. 4.  [NOTIFICATION TO CLAIMS ADMINISTRATOR.] If the 
        utilization review organization and the claims administrator are 
        separate entities, the utilization review organization 
        must forward notify, either electronically or in writing, a 
        notification of certification or determination not to certify to 
        the appropriate claims administrator for the health benefit plan 
        of any determination not to certify that is reversed on appeal. 
           Sec. 25.  Minnesota Statutes 1998, section 62M.07, is 
        amended to read: 
           62M.07 [PRIOR AUTHORIZATION OF SERVICES.] 
           (a) 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.201 62M.05, subdivision 4a 
        subdivisions 3a and 3b, 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 
        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. 
           (b) No utilization review organization, health plan 
        company, or claims administrator may conduct or require prior 
        authorization of emergency confinement or emergency treatment.  
        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 after 
        the beginning of the emergency confinement or emergency 
        treatment as reasonably possible. 
           Sec. 26.  Minnesota Statutes 1998, section 62M.09, 
        subdivision 3, is amended to read: 
           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 health care professional.  This 
        subdivision does not apply to outpatient mental health or 
        substance abuse services governed by subdivision 3a.  
           Sec. 27.  Minnesota Statutes 1998, section 62M.10, 
        subdivision 2, is amended to read: 
           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. 
           Sec. 28.  Minnesota Statutes 1998, section 62M.10, 
        subdivision 5, is amended to read: 
           Subd. 5.  [ORAL REQUESTS FOR INFORMATION.] Utilization 
        review organizations shall orally inform, upon request, 
        designated hospital personnel or the attending physician health 
        care professional 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 a provider of the 
        operational procedures in order to facilitate the review process.
           Sec. 29.  Minnesota Statutes 1998, section 62M.10, 
        subdivision 7, is amended to read: 
           Subd. 7.  [AVAILABILITY OF CRITERIA.] Upon request, a 
        utilization review organization shall provide to an enrollee or 
        to an attending physician or a provider the criteria used for a 
        specific procedure to determine the necessity, appropriateness, 
        and efficacy of that procedure and identify the database, 
        professional treatment guideline, or other basis for the 
        criteria. 
           Sec. 30.  Minnesota Statutes 1998, 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 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 
        plan companies and their providers. 
           Sec. 31.  Minnesota Statutes 1998, section 62M.15, is 
        amended to read: 
           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, 62Q, 62T, or 72A. 
           Sec. 32.  Minnesota Statutes 1998, section 62Q.106, is 
        amended to read: 
           62Q.106 [DISPUTE RESOLUTION BY COMMISSIONER.] 
           A complainant may at any time submit a complaint to the 
        appropriate commissioner to investigate.  After investigating a 
        complaint, or reviewing a company's decision, the appropriate 
        commissioner may order a remedy as authorized under section 
        62Q.30 or chapter 45, 60A, or 62D.  
           Sec. 33.  Minnesota Statutes 1998, section 62Q.19, 
        subdivision 5a, is amended to read: 
           Subd. 5a.  [COOPERATION.] Each health plan company and 
        essential community provider shall cooperate to facilitate the 
        use of the essential community provider by the high risk and 
        special needs populations.  This includes cooperation on the 
        submission and processing of claims, sharing of all pertinent 
        records and data, including performance indicators and specific 
        outcomes data, and the use of all dispute resolution methods as 
        defined in section 62Q.11, subdivision 1. 
           Sec. 34.  [62Q.68] [DEFINITIONS.] 
           Subdivision 1.  [APPLICATION.] For purposes of sections 
        62Q.68 to 62Q.72, the terms defined in this section have the 
        meanings given them.  For purposes of sections 62Q.69 and 
        62Q.70, the term "health plan company" does not include 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 or a nonprofit health service plan corporation 
        regulated under chapter 62C that only provides dental coverage 
        or vision coverage. 
           Subd. 2.  [COMPLAINT.] "Complaint" means any grievance 
        against a health plan company that is not the subject of 
        litigation and that has been submitted by a complainant to a 
        health plan company regarding the provision of health services 
        including, but not limited to, the scope of coverage for health 
        care services; retrospective denials or limitations of payment 
        for services; eligibility issues; denials, cancellations, or 
        nonrenewals of coverage; administrative operations; and the 
        quality, timeliness, and appropriateness of health care services 
        rendered.  If the complaint is from an applicant, the complaint 
        must relate to the application.  If the complaint is from a 
        former enrollee, the complaint must relate to services received 
        during the period of time the individual was an enrollee.  Any 
        grievance requiring a medical determination in its resolution 
        must have the medical determination aspect of the complaint 
        processed under the appeal procedure described in section 62M.06.
           Subd. 3.  [COMPLAINANT.] "Complainant" means an enrollee, 
        applicant, or former enrollee, or anyone acting on behalf of an 
        enrollee, applicant, or former enrollee who submits a complaint. 
           Sec. 35.  [62Q.69] [COMPLAINT RESOLUTION.] 
           Subdivision 1.  [ESTABLISHMENT.] Each health plan company 
        must establish and maintain an internal complaint resolution 
        process that meets the requirements of this section to provide 
        for the resolution of a complaint initiated by a complainant. 
           Subd. 2.  [PROCEDURES FOR FILING A COMPLAINT.] (a) A 
        complainant may submit a complaint to a health plan company 
        either by telephone or in writing.  If a complaint is submitted 
        orally and the resolution of the complaint, as determined by the 
        complainant, is partially or wholly adverse to the complainant, 
        or the oral complaint is not resolved to the satisfaction of the 
        complainant, by the health plan company within ten days of 
        receiving the complaint, the health plan company must inform the 
        complainant that the complaint may be submitted in writing.  The 
        health plan company must also offer to provide the complainant 
        with any assistance needed to submit a written complaint, 
        including an offer to complete the complaint form for a 
        complaint that was previously submitted orally and promptly mail 
        the completed form to the complainant for the complainant's 
        signature.  At the complainant's request, the health plan 
        company must provide the assistance requested by the 
        complainant.  The complaint form must include the following 
        information: 
           (1) the telephone number of the office of health care 
        consumer assistance, advocacy, and information, and the health 
        plan company member services or other departments or persons 
        equipped to advise complainants on complaint resolution; 
           (2) the address to which the form must be sent; 
           (3) a description of the health plan company's internal 
        complaint procedure and the applicable time limits; and 
           (4) the toll-free telephone number of either the 
        commissioner of health or commerce and notification that the 
        complainant has the right to submit the complaint at any time to 
        the appropriate commissioner for investigation. 
           (b) Upon receipt of a written complaint, the health plan 
        company must notify the complainant within ten business days 
        that the complaint was received, unless the complaint is 
        resolved to the satisfaction of the complainant within the ten 
        business days. 
           (c) Each health plan company must provide, in the member 
        handbook, subscriber contract, or certification of coverage, a 
        clear and concise description of how to submit a complaint and a 
        statement that, upon request, assistance in submitting a written 
        complaint is available from the health plan company. 
           Subd. 3.  [NOTIFICATION OF COMPLAINT DECISIONS.] (a) The 
        health plan company must notify the complainant in writing of 
        its decision and the reasons for it as soon as practical but in 
        no case later than 30 days after receipt of a written complaint. 
        If the health plan company cannot make a decision within 30 days 
        due to circumstances outside the control of the health plan 
        company, the health plan company may take up to 14 additional 
        days to notify the complainant of its decision.  If the health 
        plan company takes any additional days beyond the initial 30-day 
        period to make its decision, it must inform the complainant, in 
        advance, of the extension and the reasons for the extension.  
           (b) If the decision is partially or wholly adverse to the 
        complainant, the notification must inform the complainant of the 
        right to appeal the decision to the health plan company's 
        internal appeal process described in section 62Q.70 and the 
        procedure for initiating an appeal.  
           (c) The notification must also inform the complainant of 
        the right to submit the complaint at any time to either the 
        commissioner of health or commerce for investigation and the 
        toll-free telephone number of the appropriate commissioner. 
           Sec. 36.  [62Q.70] [APPEAL OF THE COMPLAINT DECISION.] 
           Subdivision 1.  [ESTABLISHMENT.] (a) Each health plan 
        company shall establish an internal appeal process for reviewing 
        a health plan company's decision regarding a complaint filed in 
        accordance with section 62Q.69.  The appeal process must meet 
        the requirements of this section.  
           (b) The person or persons with authority to resolve or 
        recommend the resolution of the internal appeal must not be 
        solely the same person or persons who made the complaint 
        decision under section 62Q.69. 
           (c) The internal appeal process must permit the receipt of 
        testimony, correspondence, explanations, or other information 
        from the complainant, staff persons, administrators, providers, 
        or other persons as deemed necessary by the person or persons 
        investigating or presiding over the appeal. 
           Subd. 2.  [PROCEDURES FOR FILING AN APPEAL.] If a 
        complainant notifies the health plan company of the 
        complainant's desire to appeal the health plan company's 
        decision regarding the complaint through the internal appeal 
        process, the health plan company must provide the complainant 
        the option for the appeal to occur either in writing or by 
        hearing. 
           Subd. 3.  [NOTIFICATION OF APPEAL DECISIONS.] (a) If a 
        complainant appeals in writing, the health plan company must 
        give the complainant written notice of the appeal decision and 
        all key findings within 30 days of the health plan company's 
        receipt of the complainant's written notice of appeal.  If a 
        complainant appeals by hearing, the health plan company must 
        give the complainant written notice of the appeal decision and 
        all key findings within 45 days of the health plan company's 
        receipt of the complainant's written notice of appeal. 
           (b) If the appeal decision is partially or wholly adverse 
        to the complainant, the notice must advise the complainant of 
        the right to submit the appeal decision to the external review 
        process described in section 62Q.73 and the procedure for 
        initiating the external process. 
           (c) Upon the request of the complainant, the health plan 
        company must provide the complainant with a complete summary of 
        the appeal decision.  
           Sec. 37.  [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 certification for health 
        care services; 
           (3) how to request an appeal either through the procedures 
        described in sections 62Q.69 and 62Q.70 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) the toll-free telephone number of the appropriate 
        commissioner; 
           (6) the telephone number of the office of consumer 
        assistance, advocacy, and information; and 
           (7) of the right to obtain an external review under section 
        62Q.73 and a description of when and how that right may be 
        exercised. 
           Sec. 38.  [62Q.72] [RECORDKEEPING; REPORTING.] 
           Subdivision 1.  [RECORDKEEPING.] Each health plan company 
        shall maintain records of all enrollee complaints and their 
        resolutions.  These records shall be retained for five years and 
        shall be made available to the appropriate commissioner upon 
        request.  An insurance company licensed under chapter 60A may 
        instead comply with section 72A.20, subdivision 30. 
           Subd. 2.  [REPORTING.] Each health plan company shall 
        submit to the appropriate commissioner, as part of the company's 
        annual filing, data on the number and type of complaints that 
        are not resolved within 30 days, or 30 business days as provided 
        under section 72A.201, subdivision 4, clause (3), for insurance 
        companies licensed under chapter 60A.  The commissioner shall 
        also make this information available to the public upon request. 
           Sec. 39.  [62Q.73] [EXTERNAL REVIEW OF ADVERSE 
        DETERMINATIONS.] 
           Subdivision 1.  [DEFINITION.] For purposes of this section, 
        adverse determination means:  
           (1) 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; 
           (2) any initial determination not to certify that has been 
        appealed in accordance with section 62M.06 and the appeal did 
        not reverse the initial determination not to certify; or 
           (3) 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. 
        An adverse determination does not include complaints relating to 
        fraudulent marketing practices or agent misrepresentation. 
           Subd. 2.  [EXCEPTION.] (a) This section does not apply to 
        governmental programs except as permitted under paragraph (b).  
        For purposes of this subdivision, "governmental programs" means 
        the prepaid medical assistance program, the MinnesotaCare 
        program, the prepaid general assistance medical care program, 
        and the federal Medicare program. 
           (b) In the course of a recipient's appeal of a medical 
        determination to the commissioner of human services under 
        section 256.045, the recipient may request an expert medical 
        opinion be arranged by the external review entity under contract 
        to provide independent external reviews under this section.  If 
        such a request is made, the cost of the review shall be paid by 
        the commissioner of human services.  Any medical opinion 
        obtained under this paragraph shall only be used by a state 
        human services referee as evidence in the recipient's appeal to 
        the commissioner of human services under section 256.045.  
           (c) Nothing in this subdivision shall be construed to limit 
        or restrict the appeal rights provided in section 256.045 for 
        governmental program recipients. 
           Subd. 3.  [RIGHT TO EXTERNAL REVIEW.] (a) Any enrollee or 
        anyone acting on behalf of an enrollee who has received an 
        adverse determination may submit a written request for an 
        external review of the adverse determination, if applicable 
        under section 62Q.68, subdivision 1, or 62M.06, to the 
        commissioner of health if the request involves a health plan 
        company regulated by that commissioner or to the commissioner of 
        commerce if the request involves a health plan company regulated 
        by that commissioner.  The written request must be accompanied 
        by a filing fee of $25.  The fee may be waived by the 
        commissioner of health or commerce in cases of financial 
        hardship. 
           (b) Nothing in this section requires the commissioner of 
        health or commerce to independently investigate an adverse 
        determination referred for independent external review. 
           (c) If an enrollee requests an external review, the health 
        plan company must participate in the external review.  The cost 
        of the external review in excess of the filing fee described in 
        paragraph (a) shall be borne by the health plan company.  
           Subd. 4.  [CONTRACT.] Pursuant to a request for proposal, 
        the commissioner of administration, in consultation with the 
        commissioners of health and commerce, shall contract with an 
        organization or business entity to provide independent external 
        reviews of all adverse determinations submitted for external 
        review.  The contract shall ensure that the fees for services 
        rendered in connection with the reviews be reasonable. 
           Subd. 5.  [CRITERIA.] (a) The request for proposal must 
        require that the entity demonstrate: 
           (1) no conflicts of interest in that it is not owned, a 
        subsidiary of, or affiliated with a health plan company or 
        utilization review organization; 
           (2) an expertise in dispute resolution; 
           (3) an expertise in health related law; 
           (4) an ability to conduct reviews using a variety of 
        alternative dispute resolution procedures depending upon the 
        nature of the dispute; 
           (5) an ability to provide data to the commissioners of 
        health and commerce on reviews conducted; and 
           (6) an ability to ensure confidentiality of medical records 
        and other enrollee information. 
           (b) The commissioner of administration shall take into 
        consideration, in awarding the contract according to subdivision 
        4, any national accreditation standards that pertain to an 
        external review entity. 
           Subd. 6.  [PROCESS.] (a) Upon receiving a request for an 
        external review, the external review entity must provide 
        immediate notice of the review to the enrollee and to the health 
        plan company.  Within ten business days of receiving notice of 
        the review the health plan company and the enrollee must provide 
        the external review entity with any information that they wish 
        to be considered.  Each party shall be provided an opportunity 
        to present its version of the facts and arguments.  An enrollee 
        may be assisted or represented by a person of the enrollee's 
        choice. 
           (b) As part of the external review process, any aspect of 
        an external review involving a medical determination must be 
        performed by a health care professional with expertise in the 
        medical issue being reviewed. 
           (c) An external review shall be made as soon as practical 
        but in no case later than 40 days after receiving the request 
        for an external review and must promptly send written notice of 
        the decision and the reasons for it to the enrollee, the health 
        plan company, and to the commissioner who is responsible for 
        regulating the health plan company. 
           Subd. 7.  [STANDARDS OF REVIEW.] (a) For an external review 
        of any issue in an adverse determination that does not require a 
        medical necessity determination, the external review must be 
        based on whether the adverse determination was in compliance 
        with the enrollee's health benefit plan. 
           (b) For an external review of any issue in an adverse 
        determination by a health plan company licensed under chapter 
        62D that requires a medical necessity determination, the 
        external review must determine whether the adverse determination 
        was consistent with the definition of medically necessary care 
        in Minnesota Rules, part 4685.0100, subpart 9b. 
           (c) For an external review of any issue in an adverse 
        determination by a health plan company, other than a health plan 
        company licensed under chapter 62D, that requires a medical 
        necessity determination, the external review must determine 
        whether the adverse determination was consistent with the 
        definition of medically necessary care in section 62Q.53, 
        subdivision 2. 
           Subd. 8.  [EFFECTS OF EXTERNAL REVIEW.] A decision rendered 
        under this section shall be nonbinding on the enrollee and 
        binding on the health plan company.  The health plan company may 
        seek judicial review of the decision on the grounds that the 
        decision was arbitrary and capricious or involved an abuse of 
        discretion. 
           Subd. 9.  [IMMUNITY FROM CIVIL LIABILITY.] A person who 
        participates in an external review by investigating, reviewing 
        materials, providing technical expertise, or rendering a 
        decision shall not be civilly liable for any action that is 
        taken in good faith, that is within the scope of the person's 
        duties, and that does not constitute willful or reckless 
        misconduct. 
           Subd. 10.  [DATA REPORTING.] The commissioners shall make 
        available to the public, upon request, summary data on the 
        decisions rendered under this section, including the number of 
        reviews heard and decided and the final outcomes.  Any data 
        released to the public must not individually identify the 
        enrollee initiating the request for external review. 
           Sec. 40.  Minnesota Statutes 1998, section 62T.04, is 
        amended to read: 
           62T.04 [COMPLAINT SYSTEM.] 
           Accountable provider networks must establish and maintain 
        an enrollee complaint system as required under section 
        62Q.105 sections 62Q.68 to 62Q.72.  The accountable provider 
        network may contract with the health care purchasing alliance or 
        a vendor for operation of this system. 
           Sec. 41.  Minnesota Statutes 1998, section 72A.201, 
        subdivision 4a, is amended to read: 
           Subd. 4a.  [STANDARDS FOR PREAUTHORIZATION APPROVAL.] If a 
        policy of accident and sickness insurance or a subscriber 
        contract requires preauthorization approval for any nonemergency 
        services or benefits, the decision to approve or disapprove the 
        requested services or benefits must be communicated to the 
        insured or the insured's health care provider within ten 
        business days of the preauthorization request provided that all 
        information reasonably necessary to make a decision on the 
        request has been made available to the insurer processed in 
        accordance with section 62M.07. 
           Sec. 42.  Minnesota Statutes 1998, section 256B.692, 
        subdivision 2, is amended to read: 
           Subd. 2.  [DUTIES OF THE COMMISSIONER OF HEALTH.] 
        Notwithstanding chapters 62D and 62N, a county that elects to 
        purchase medical assistance and general assistance medical care 
        in return for a fixed sum without regard to the frequency or 
        extent of services furnished to any particular enrollee is not 
        required to obtain a certificate of authority under chapter 62D 
        or 62N.  A county that elects to purchase medical assistance and 
        general assistance medical care services under this section must 
        satisfy the commissioner of health that the requirements of 
        chapter 62D, applicable to health maintenance organizations, or 
        chapter 62N, applicable to community integrated service 
        networks, will be met.  A county must also assure the 
        commissioner of health that the requirements of sections 
        62J.041; 62J.48; 62J.71 to 62J.73; 62M.01 to 62M.16; all 
        applicable provisions of chapter 62Q, including sections 62Q.07; 
        62Q.075; 62Q.105; 62Q.1055; 62Q.106; 62Q.11; 62Q.12; 62Q.135; 
        62Q.14; 62Q.145; 62Q.19; 62Q.23, paragraph (c); 62Q.30; 62Q.43; 
        62Q.47; 62Q.50; 62Q.52 to 62Q.56; 62Q.58; 62Q.64; 62Q.68 to 
        62Q.72; and 72A.201 will be met.  All enforcement and rulemaking 
        powers available under chapters 62D, 62J, 62M, 62N, and 62Q are 
        hereby granted to the commissioner of health with respect to 
        counties that purchase medical assistance and general assistance 
        medical care services under this section. 
           Sec. 43.  [REPEALER.] 
           (a) Minnesota Statutes 1998, section 62D.11, subdivisions 
        1b and 2, are repealed.  
           (b) Minnesota Statutes 1998, sections 62Q.105; 62Q.11; and 
        62Q.30, are repealed. 
           (c) Minnesota Rules, parts 4685.0100, subparts 4 and 4a; 
        and 4685.1700, are repealed. 
           (d) Minnesota Rules, part 4685.1010, subpart 3, is repealed.
           Sec. 44.  [EFFECTIVE DATE.] 
           Sections 1, 3 to 42, and 43, paragraphs (a) and (c), are 
        effective April 1, 2000, and apply to contracts issued or 
        renewed on or after that date.  Upon request, the commissioner 
        of health or commerce shall grant an extension of up to three 
        months to any health plan company or utilization review 
        organization that is unable to comply with sections 1, 3 to 42, 
        and 43, paragraphs (a) and (c) by April 1, 2000, due to 
        circumstances beyond the control of the health plan company or 
        utilization review organization.  
           Section 43, paragraph (b), is effective July 1, 1999. 
           Sections 2 and 43, paragraph (d), are effective January 1, 
        2000, and apply to contracts issued or renewed on or after that 
        date. 
           Presented to the governor May 24, 1999 
           Signed by the governor May 25, 1999, 11:50 a.m.