Minnesota Administrative Rules

9505.5078 RECONSIDERATION.

Subpart 1.

Reconsideration requested by physician.

If a second physician adviser determines a surgical procedure is not medically appropriate, an admitting physician requesting the second medical opinion may request reconsideration. The admitting physician who wants reconsideration must submit a written request to the medical review agent within 30 days of the date of receipt of the notice in part 9505.5077. The request must have the recipient's name and health care program identification number, the disputed surgery, the reason for the dispute, the medical record or part of the medical record needed to make a determination of medical appropriateness, any other relevant information, and the name, address, and telephone number of the physician.

Subp. 2.

Reconsideration; three physician advisers.

Upon receipt of a reconsideration requested under subpart 1, the medical review agent shall appoint at least three physician advisers who did not take part in the determination leading to a denial of an authorization number. Each physician adviser shall determine the medical appropriateness of the surgical procedure. The reconsideration decision shall be the opinion of the majority of the physician advisers. The reconsideration must be completed within 60 days of the receipt of the information required under subpart 1.

Subp. 3.

Reconsideration; medical review agent.

Upon completion of the reconsideration, the medical review agent shall notify the admitting physician by telephone within 24 hours of the decision, exclusive of weekends and holidays. Additionally, the medical review agent shall send, by certified mail, the admitting physician and the recipient the written notices required under part 9505.5082 no later than ten days following the decision, exclusive of weekends and holidays. The notice to the recipient must state the right of the recipient to appeal under part 9505.5105 and Minnesota Statutes, section 256.045. If the admitting physician has already performed the surgery, the notice to the admitting physician must state the right of the admitting physician to appeal under the contested case procedure under Minnesota Statutes, chapter 14.

Statutory Authority:

MS s 256.0625; 256.991; 256D.03

History:

20 SR 2405

Published Electronically:

August 12, 2008