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Minnesota Legislature

Office of the Revisor of Statutes

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

                            CHAPTER 137-S.F.No. 414 
                  An act relating to health; modifying the Minnesota 
                  Utilization Review Act; adding criteria specifying 
                  when the board of medical practice may impose 
                  disciplinary action; amending Minnesota Statutes 2000, 
                  sections 62M.06, subdivision 3; 62M.09, subdivisions 
                  3, 3a, 6, by adding a subdivision; 62M.10, subdivision 
                  7; 147.091, by adding a subdivision. 
        BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
           Section 1.  Minnesota Statutes 2000, section 62M.06, 
        subdivision 3, is amended to read: 
           Subd. 3.  [STANDARD APPEAL.] The utilization review 
        organization must establish procedures for appeals to be made 
        either in writing or by telephone. 
           (a) A utilization review organization shall notify in 
        writing the enrollee, attending health care professional, and 
        claims administrator of its determination 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 
        professional. 
           (c) Prior to upholding the 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 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 enrollee and attending health care 
        professional when the initial determination is made. 
           (e) An attending 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 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. 
           Sec. 2.  Minnesota Statutes 2000, section 62M.09, 
        subdivision 3, is amended to read: 
           Subd. 3.  [PHYSICIAN REVIEWER INVOLVEMENT.] (a) 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.  
           (b) The physician conducting the review must be licensed in 
        this state.  This paragraph does not apply to reviews conducted 
        in connection with policies issued by a health plan company that 
        is assessed less than three percent of the total amount assessed 
        by the Minnesota comprehensive health association.  
           (c) The physician should be reasonably available by 
        telephone to discuss the determination with the attending health 
        care professional.  
           (d) This subdivision does not apply to outpatient mental 
        health or substance abuse services governed by subdivision 3a. 
           Sec. 3.  Minnesota Statutes 2000, section 62M.09, 
        subdivision 3a, is amended to read: 
           Subd. 3a.  [MENTAL HEALTH AND SUBSTANCE ABUSE REVIEWS.] A 
        peer of the treating mental health or substance abuse provider 
        or a physician must review requests for outpatient services in 
        which the utilization review organization has concluded that a 
        determination not to certify a mental health or substance abuse 
        service for clinical reasons is appropriate, provided that any 
        final determination not to certify treatment is made by a 
        psychiatrist certified by the American Board of Psychiatry and 
        Neurology and appropriately licensed in the this state in which 
        the psychiatrist resides.  Notwithstanding the notification 
        requirements of section 62M.05, a utilization review 
        organization that has made an initial decision to certify in 
        accordance with the requirements of section 62M.05 may elect to 
        provide notification of a determination to continue coverage 
        through facsimile or mail.  This subdivision does not apply to 
        determinations made in connection with policies issued by a 
        health plan company that is assessed less than three percent of 
        the total amount assessed by the Minnesota comprehensive health 
        association. 
           Sec. 4.  Minnesota Statutes 2000, section 62M.09, 
        subdivision 6, is amended to read: 
           Subd. 6.  [PHYSICIAN CONSULTANTS.] A utilization review 
        organization must use physician consultants in the appeal 
        process described in section 62M.06, subdivision 3.  The 
        physician consultants should include, as needed and available, 
        specialists who are must be 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. 
           Sec. 5.  Minnesota Statutes 2000, section 62M.09, is 
        amended by adding a subdivision to read: 
           Subd. 9.  [ANNUAL REPORT.] A utilization review 
        organization shall file an annual report with the annual 
        financial statement it submits to the commissioner of commerce 
        that includes: 
           (1) per 1,000 claims, the number and rate of claims denied 
        based on medical necessity for each procedure or service; and 
           (2) the number and rate of denials overturned on appeal. 
           Sec. 6.  Minnesota Statutes 2000, 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 a, a provider, and the commissioner of commerce the criteria 
        used for a specific procedure to determine the medical 
        necessity, appropriateness, and efficacy of that a procedure or 
        service and identify the database, professional treatment 
        guideline, or other basis for the criteria. 
           Sec. 7.  Minnesota Statutes 2000, section 147.091, is 
        amended by adding a subdivision to read: 
           Subd. 1b.  [UTILIZATION REVIEW.] The board may investigate 
        allegations and impose disciplinary action as described in 
        section 147.141 against a physician performing utilization 
        review for a pattern of failure to exercise that degree of care 
        that a physician reviewer of ordinary prudence making 
        utilization review determinations for a utilization review 
        organization would use under the same or similar circumstances.  
        As part of its investigative process, the board shall receive 
        consultation or recommendation from physicians who are currently 
        engaged in utilization review activities.  The internal and 
        external review processes under sections 62M.06 and 62Q.73 must 
        be exhausted prior to an allegation being brought under this 
        subdivision.  Nothing in this subdivision creates, modifies, or 
        changes existing law related to tort liability for medical 
        negligence.  Nothing in this subdivision preempts state peer 
        review law protection in accordance with sections 145.61 to 
        145.67, federal peer review law, or current law pertaining to 
        complaints or appeals. 
           Presented to the governor May 17, 2001 
           Signed by the governor May 21, 2001, 10:58 a.m.