1.1                          A bill for an act 
  1.2             relating to health; modifying review and complaint 
  1.3             procedures for health plans; amending Minnesota 
  1.4             Statutes 1998, sections 62M.05, by adding a 
  1.5             subdivision; 62M.06, subdivisions 2, 3, and by adding 
  1.6             a subdivision; and 62Q.105; proposing coding for new 
  1.7             law in Minnesota Statutes, chapter 62Q; repealing 
  1.8             Minnesota Statutes 1998, sections 62D.11; 62Q.105, 
  1.9             subdivision 2; 62Q.11; and 62Q.30; Minnesota Rules, 
  1.10            part 4685.1700, subpart 1. 
  1.11  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.12     Section 1.  Minnesota Statutes 1998, section 62M.05, is 
  1.13  amended by adding a subdivision to read: 
  1.14     Subd. 3b.  [EXPEDITED REVIEW DETERMINATION.] An expedited 
  1.15  initial determination must be utilized if the attending 
  1.16  physician believes that the determination warrants immediate 
  1.17  review.  Notification of an expedited initial determination 
  1.18  either to certify or not to certify must be provided to the 
  1.19  attending physician no later than 72 hours from the initial 
  1.20  request.  The notice must include the principal reason or 
  1.21  reasons for the determination and, upon request, the criteria 
  1.22  used to determine the necessity, appropriateness, and efficacy 
  1.23  of the health care service and identification of the database, 
  1.24  professional treatment parameter, or other basis for the 
  1.25  criteria.  Reasons for a determination not to certify may 
  1.26  include, among other things, the lack of adequate information to 
  1.27  certify after a reasonable attempt has been made to contact the 
  1.28  attending physician.  When an expedited initial determination is 
  2.1   made not to certify, the utilization review organization must 
  2.2   notify the attending physician of the right to an expedited 
  2.3   appeal and the procedure for initiating an appeal.  An expedited 
  2.4   review or appeal shall not be required for retrospective adverse 
  2.5   determinations. 
  2.6      Sec. 2.  Minnesota Statutes 1998, section 62M.06, 
  2.7   subdivision 2, is amended to read: 
  2.8      Subd. 2.  [EXPEDITED APPEAL.] When an initial determination 
  2.9   not to certify a health care service is made prior to or during 
  2.10  an ongoing service requiring review, and the attending physician 
  2.11  believes that the determination warrants immediate appeal, the 
  2.12  utilization review organization must ensure that the attending 
  2.13  physician, enrollee, or designee has an opportunity to appeal 
  2.14  the determination over the telephone on an expedited basis.  In 
  2.15  such an appeal, the utilization review organization must ensure 
  2.16  reasonable access to its consulting physician.  Notification of 
  2.17  an expedited appeal either to certify or not to certify must be 
  2.18  provided to the attending physician no later than 72 hours from 
  2.19  the request for expedited appeal.  Expedited appeals that are 
  2.20  not resolved may be resubmitted through the standard appeal 
  2.21  process. 
  2.22     Sec. 3.  Minnesota Statutes 1998, section 62M.06, 
  2.23  subdivision 3, is amended to read: 
  2.24     Subd. 3.  [STANDARD APPEAL.] The utilization review 
  2.25  organization must establish procedures for appeals to be made 
  2.26  either in writing or by telephone. 
  2.27     (a) Each utilization review organization shall notify in 
  2.28  writing the enrollee or patient, attending physician, and claims 
  2.29  administrator of its determination on the appeal as soon as 
  2.30  practical, but in no case later than 45 days after receiving the 
  2.31  required documentation on the appeal. 
  2.32     (b) The documentation required by the utilization review 
  2.33  organization may include copies of part or all of the medical 
  2.34  record and a written statement from the health care provider. 
  2.35     (c) Prior to upholding the original decision not to certify 
  2.36  for clinical reasons, the utilization review organization shall 
  3.1   conduct a review of the documentation by a physician who did not 
  3.2   make the original determination not to certify. 
  3.3      (d) The process established by a utilization review 
  3.4   organization may include defining a period within which an 
  3.5   appeal must be filed to be considered.  The time period must be 
  3.6   communicated to the patient, enrollee, or attending physician 
  3.7   when the initial determination is made. 
  3.8      (e) An attending physician who has been unsuccessful in an 
  3.9   attempt to reverse a determination not to certify shall, 
  3.10  consistent with section 72A.285, be provided the following: 
  3.11     (1) a complete summary of the review findings; 
  3.12     (2) qualifications of the reviewers, including any license, 
  3.13  certification, or specialty designation; and 
  3.14     (3) the relationship between the enrollee's diagnosis and 
  3.15  the review criteria used as the basis for the decision, 
  3.16  including the specific rationale for the reviewer's decision. 
  3.17     (f) In cases of appeal to reverse a determination not to 
  3.18  certify for clinical reasons, the utilization review 
  3.19  organization must, upon request of the attending physician, 
  3.20  ensure that a physician of the utilization review organization's 
  3.21  choice in the same or a similar general specialty as typically 
  3.22  manages the medical condition, procedure, or treatment under 
  3.23  discussion is reasonably available to review the case. 
  3.24     (g) If the initial determination is not reversed in the 
  3.25  first level of appeal, the utilization review organization may 
  3.26  include in its notification the right to submit the appeal to 
  3.27  the utilization review organization for a written 
  3.28  reconsideration or a hearing. 
  3.29     Sec. 4.  Minnesota Statutes 1998, section 62M.06, is 
  3.30  amended by adding a subdivision to read: 
  3.31     Subd. 5.  [WRITTEN RECONSIDERATION OR HEARING.] (a) If the 
  3.32  enrollee chooses a written reconsideration, a person or persons 
  3.33  with authority to resolve the appeal shall review the case, but 
  3.34  the person or persons conducting the review shall not be solely 
  3.35  the same person or persons who made the prior review decision. 
  3.36     (b) If the enrollee chooses a hearing, a person or persons 
  4.1   with authority to resolve or recommend the resolution of the 
  4.2   appeal shall preside, but the person or persons presiding must 
  4.3   not be solely the same person or persons who made the prior 
  4.4   review decision. 
  4.5      (c) A hearing or written reconsideration must allow the 
  4.6   receipt of testimony, correspondence, explanations, or other 
  4.7   information from the enrollee, providers, or other persons as is 
  4.8   deemed necessary by the person or persons presiding over the 
  4.9   appeal. 
  4.10     (d) In the case of a written reconsideration, a concise 
  4.11  written notice of all key findings must be sent to the enrollee 
  4.12  and attending physician within 30 days of the utilization review 
  4.13  organization's receipt of the written request for written 
  4.14  reconsideration. 
  4.15     (e) In the case of a hearing, a concise written notice of 
  4.16  all key findings must be sent to the enrollee and attending 
  4.17  physician within 45 days after the utilization review 
  4.18  organization receives the written request for a hearing. 
  4.19     (f) If the decision is partially or wholly adverse to the 
  4.20  enrollee and the subject of the review pertains to experimental 
  4.21  or investigative therapy for an enrollee with a terminal 
  4.22  condition, the utilization review organization must include in 
  4.23  its notification the right to submit the appeal to an external 
  4.24  independent medical review process. 
  4.25     Sec. 5.  [62Q.103] [DEFINITIONS.] 
  4.26     Subdivision 1.  [APPLICATION.] For purposes of sections 
  4.27  62Q.103 and 62Q.105, the terms defined in this section have the 
  4.28  meanings given them. 
  4.29     Subd. 2.  [COMPLAINT.] "Complaint" means any written 
  4.30  grievance against a health plan, which is not the subject of 
  4.31  litigation and which has been submitted by a complainant 
  4.32  regarding the provision of health care services, including the 
  4.33  scope of coverage for health care services; retrospective 
  4.34  denials or limitations of payment for services; eligibility 
  4.35  issues; denials, cancellations, or nonrenewals of coverage; 
  4.36  administrative operations; and the quality, timelines, and 
  5.1   appropriateness of health care services rendered.  Any grievance 
  5.2   requiring a medical determination in its resolution shall have 
  5.3   the medical determination component processed under chapter 
  5.4   62M.  If the complaint is from a former enrollee, the complaint 
  5.5   must relate to services received during the time the individual 
  5.6   was an enrollee. 
  5.7      Subd. 3.  [COMPLAINANT.] "Complainant" means an enrollee or 
  5.8   former enrollee, or anyone duly authorized to act on behalf of 
  5.9   an enrollee or former enrollee, who submits a complaint. 
  5.10     Sec. 6.  Minnesota Statutes 1998, section 62Q.105, is 
  5.11  amended to read: 
  5.12     62Q.105 [HEALTH PLAN COMPANY COMPLAINT PROCEDURE.] 
  5.13     Subdivision 1.  [ESTABLISHMENT.] Each health plan ~~company~~, 
  5.14  including an accountable provider network operating under 
  5.15  chapter 62T, shall establish and make available to enrollees, by 
  5.16  July 1, 1999, ~~an informal~~ a complaint resolution process that 
  5.17  meets the requirements of this section.  The complaint 
  5.18  resolution process under this section shall not apply to the 
  5.19  Minnesota comprehensive health association or government 
  5.20  programs, including Medicare, Medicaid, general assistance 
  5.21  medical care, and MinnesotaCare.  A health plan ~~company~~ must 
  5.22  make reasonable efforts to resolve enrollee complaints~~, and must~~ 
  5.23  ~~inform complainants in writing of the company's decision within~~ 
  5.24  ~~30 days of receiving the complaint~~.  If the complaint pertains 
  5.25  to a retrospective denial or limitation of services, the 
  5.26  complaint must be submitted within 60 days of receipt of the 
  5.27  notice of denial or limitation of services.  All other 
  5.28  complaints must be submitted within 60 days of when the patient 
  5.29  knew or should have known of the reason to file a complaint.  
  5.30  The complaint resolution process must treat the complaint and 
  5.31  information related to it as required under sections 72A.49 to 
  5.32  72A.505.  
  5.33     ~~Subd. 2.  [MEDICALLY URGENT COMPLAINTS.] Health plan~~ 
  5.34  ~~companies shall make reasonable efforts to resolve medically~~ 
  5.35  ~~urgent enrollee complaints within 72 hours of receiving the~~ 
  5.36  ~~complaint.~~  
  6.1      Subd. 2a.  [PROCEDURES FOR FILING COMPLAINT.] (a) An 
  6.2   enrollee or former enrollee may submit a verbal concern by 
  6.3   </u>
  6.4   telephone or a complaint in writing.  If a concern is submitted 
  6.5   verbally and the resolution of the concern is partially or 
  6.6   wholly adverse to the enrollee or former enrollee, the health 
  6.7   plan must inform the enrollee or former enrollee that the verbal 
  6.8   concern may be submitted in writing and must promptly mail a 
  6.9   complaint form.  The complaint form must include the following 
  6.10  information: 
  6.11     (1) the telephone number of the office of health care 
  6.12  consumer assistance, advocacy, and information, and the health 
  6.13  plan member services or other departments or persons equipped to 
  6.14  advise complainants on complaint resolution; 
  6.15     (2) the address to which the form must be sent; 
  6.16     (3) a description of the health plan's internal complaint 
  6.17  procedure and the applicable time limits; and 
  6.18     (4) the toll-free telephone number of either the 
  6.19  commissioner of health or commerce and notification that the 
  6.20  complainant has the right to submit the complaint at any time to 
  6.21  the appropriate commissioner for investigation. 
  6.22     (b) Upon receipt of a written complaint, the health plan 
  6.23  must notify the complainant within ten business days that the 
  6.24  complaint was received, unless the complaint is resolved to the 
  6.25  satisfaction of the complainant prior to that time. 
  6.26     (c) At the complainant's request, a health plan must 
  6.27  provide a complainant with assistance as needed to file a 
  6.28  written complaint. 
  6.29     (d) Each health plan must provide, in the subscriber 
  6.30  contract or certificate of coverage, a clear and concise 
  6.31  description of how to submit a complaint and a statement that, 
  6.32  upon request, assistance in submitting a written complaint is 
  6.33  available from the health plan for complainants in need. 
  6.34     Subd. 2b.  [NOTICE OF COMPLAINT DECISION.] Within 45 days 
  6.35  of receipt of all necessary information, the health plan must 
  6.36  notify the complainant in writing of its decision and the 
  6.37  reasons for it.  If the decision is partially or wholly adverse 
  7.1   to the complainant, the notification must advise the complainant 
  7.2   of the following: 
  7.3      (1) the right to appeal the decision through the health 
  7.4   plan's internal appeals process, either through a written 
  7.5   reconsideration or a hearing, and the process for initiating an 
  7.6   appeal, including the applicable timelines; 
  7.7      (2) the right to file an appeal within 60 days from the 
  7.8   date of receipt of notice of the right to appeal; and 
  7.9      (3) the telephone number of the appropriate commissioner 
  7.10  and notification that the complainant has the right to submit 
  7.11  the complaint to the commissioner for investigation. 
  7.12     Subd. 3.  [~~APPEALS PROCESS~~ WRITTEN RECONSIDERATION OR 
  7.13  HEARING.] Health ~~plan companies~~ plans shall establish and make 
  7.14  available to ~~enrollees~~ complainants an ~~impartial~~ internal 
  7.15  appeals process~~.  If a decision by a health plan company~~ 
  7.16  ~~regarding a complaint is partially or wholly adverse to the~~ 
  7.17  ~~complainant, the health plan company shall advise the~~ 
  7.18  ~~complainant of the right to appeal through the impartial appeals~~ 
  7.19  ~~process or to the commissioner.~~ that includes a written 
  7.20  reconsideration and hearing as follows:  
  7.21     (1) if the complainant chooses a written reconsideration, a 
  7.22  person or persons with authority to resolve the complaint shall 
  7.23  investigate the complaint, but the person or persons 
  7.24  investigating must not be solely the same person or persons who 
  7.25  made the initial complaint review decision; 
  7.26     (2) if the complainant chooses a hearing, a person or 
  7.27  persons with authority to resolve the complaint shall preside, 
  7.28  but the person or persons presiding must not be solely the same 
  7.29  person or persons who made the initial complaint review 
  7.30  decision; 
  7.31     (3) a hearing or written reconsideration must allow the 
  7.32  receipt of testimony, correspondence, explanations, or other 
  7.33  information from the complainant, providers, or other persons as 
  7.34  is deemed necessary by the person or persons investigating the 
  7.35  complaint in the case of a reconsideration, or presiding person 
  7.36  or persons in the case of a hearing for a fair appraisal and 
  8.1   resolution of the complaint; 
  8.2      (4) in the case of a written reconsideration, a concise 
  8.3   written notice of all key findings must be given to the 
  8.4   complainant within 30 days of the health plan's receipt of the 
  8.5   complainant's written notice of appeal; 
  8.6      (5) in the case of a hearing, a concise written notice of 
  8.7   all key findings must be given to the complainant within 45 days 
  8.8   after the health plan receives the complainant's written notice 
  8.9   of appeal; and 
  8.10     (6) if the appeal decision is partially or wholly adverse 
  8.11  to the complainant, the notification of the decision must 
  8.12  include the right to request arbitration within 60 days of 
  8.13  receipt of the notice and the procedure for initiating the 
  8.14  process.  The internal appeals process, including a written 
  8.15  reconsideration or a hearing, must be exhausted prior to 
  8.16  arbitration. 
  8.17     Subd. 4.  [~~ALTERNATIVE DISPUTE RESOLUTION~~ ARBITRATION.] 
  8.18  Health ~~plan companies~~ plans shall make available to ~~enrollees an~~ 
  8.19  ~~alternative dispute resolution process~~ complainants arbitration 
  8.20  after the exhaustion of the internal complaint review and 
  8.21  appeals processes, and shall participate in ~~alternative dispute~~ 
  8.22  ~~resolution~~ arbitration at the request of ~~an enrollee, as~~ 
  8.23  ~~required under section 62Q.11~~ a complainant.  If a complaint 
  8.24  includes a medical necessity or appropriateness issue, the 
  8.25  medical necessity or appropriateness component of the complaint 
  8.26  must be considered under chapter 62M and is not eligible for 
  8.27  arbitration under this section.  Complaints regarding employer 
  8.28  initiated actions, agent misrepresentation, or premiums are not 
  8.29  subject to arbitration.  A medical malpractice damage claim is 
  8.30  not subject to arbitration, unless agreed to in writing by all 
  8.31  parties subsequent to the event giving rise to the claim.  ~~A~~ 
  8.32  ~~health plan company may meet the requirements of subdivision 3~~ 
  8.33  ~~by providing an alternative dispute resolution process.  If the~~ 
  8.34  ~~health plan company chooses to provide alternative dispute~~ 
  8.35  ~~resolution to meet the requirements of subdivision 3, the~~ 
  8.36  ~~process shall be provided at no cost to the enrollee.~~ 
  9.1      Subd. 5.  [REQUIREMENTS FOR MANAGED CARE ORGANIZATIONS.] 
  9.2   Each managed care organization shall submit all health care 
  9.3   quality related complaints to its quality review board or 
  9.4   quality review organization for evaluation and possible action.  
  9.5   The complaint resolution process for managed care organizations 
  9.6   must clearly indicate the entity responsible for resolving 
  9.7   complaints made by enrollees against hospitals, other health 
  9.8   care facilities, and health care providers, that are owned by or 
  9.9   under contract with the managed care organization. 
  9.10     Subd. 6.  [RECORDKEEPING.] Health ~~plan companies~~ plans 
  9.11  shall maintain records of all enrollee complaints and their 
  9.12  resolutions.  These records must be retained for five years, and 
  9.13  must be made available to the appropriate commissioner upon 
  9.14  request. 
  9.15     Subd. 7.  [REPORTING.] Each health plan ~~company~~ shall 
  9.16  submit to the appropriate commissioner, as part of the company's 
  9.17  annual filing, data on the number and type of complaints that 
  9.18  are not resolved within ~~30~~ 45 days.  ~~A health plan company shall~~ 
  9.19  ~~also make this information available to the public upon request.~~ 
  9.20     Subd. 8.  [NOTICE TO ENROLLEES.] Health ~~plan companies~~ 
  9.21  plans shall provide a clear and complete description of their 
  9.22  complaint resolution procedures to enrollees as part of their 
  9.23  ~~evidence~~ subscriber contracts or certificates of coverage ~~or~~ 
  9.24  ~~contract~~.  The description must specifically inform enrollees: 
  9.25     (1) how to file a complaint with the health plan ~~company~~; 
  9.26     (2) how to request an ~~impartial~~ appeal through a written 
  9.27  reconsideration or a hearing as described in subdivision 4; 
  9.28     (3) that they have the right to file a complaint with 
  9.29  either the commissioner of health or commerce at any time during 
  9.30  the complaint process; 
  9.31     (4) the telephone number of the appropriate commissioner; 
  9.32     (5) the telephone number of the office of consumer 
  9.33  assistance, advocacy, and information; and 
  9.34     (6) that they have the right to request the use of 
  9.35  ~~alternative methods of dispute resolution; and~~ 
  9.36     ~~(4) that they have the right to litigate~~ arbitration after 
 10.1   exhaustion of the internal appeals process. 
 10.2      Subd. 9.  [STAY OF PROCEDURES.] Procedures under this 
 10.3   section are stayed when a complainant files suit against a 
 10.4   health plan, or when the complainant makes the health plan a 
 10.5   party to the complainant's suit against another party concerning 
 10.6   the facts giving rise to the complaint.  Upon a decision on the 
 10.7   merits of a suit, the complainant shall be deemed to have waived 
 10.8   the remedies under this section.  If a complainant's case is 
 10.9   dismissed for reasons other than on the merits or if the 
 10.10  complainant and health plan agree, a complainant may have access 
 10.11  to procedures under this section. 
 10.12     Sec. 7.  [REPEALER.] 
 10.13     Minnesota Statutes 1998, sections 62D.11; 62Q.105, 
 10.14  subdivision 2; 62Q.11; and 62Q.30, are repealed.  
 10.15     Minnesota Rules, part 4685.1700, subpart 1, is repealed.