Minnesota Administrative Rules

5218.0900 SUSPENSION; REVOCATION.

Subpart 1.

Complaints; investigation.

Complaints pertaining to violations of parts 5218.0010 to 5218.0900 or Minnesota Statutes, section 176.1351, by the managed care plan shall be directed in writing to the commissioner. On receipt of a written complaint, or after monitoring the managed care plan operations, the department shall investigate the alleged violation. The investigation may include, but shall not be limited to, request for and review of pertinent managed care plan records. If the investigation reveals reasonable cause to believe that there has been a violation warranting suspension or revocation of certification, the commissioner shall initiate a contested case proceeding under Minnesota Statutes, chapter 14.

Subp. 2.

Criteria.

Under Minnesota Statutes, section 176.1351, subdivision 5, the certification of a managed care plan issued by the commissioner shall be suspended or revoked by the commissioner if:

A.

service under the plan is not being provided according to the terms of the certified plan;

B.

the plan for providing services or the contract with the insurer or health care provider fails to meet the requirements of parts 5218.0010 to 5218.0900 or Minnesota Statutes, section 176.1351;

C.

the managed care plan fails to comply with parts 5218.0010 to 5218.0900 and Minnesota Statutes, section 176.1351, or requirements of utilization and treatment standards adopted under Minnesota Statutes, section 176.83;

D.

any false or misleading information is submitted by the managed care plan or participating provider;

E.

the managed care plan continues to use the services of a health care provider whose license, registration, or certification has been suspended or revoked, or under Minnesota Statutes, section 176.103, or who is ineligible to provide treatment to an injured employee under Minnesota Statutes, section 256B.0644; or

F.

the managed care plan is formed, owned, or operated by an insurer.

Subp. 3.

Effects.

No employee is covered by a contract between a managed care plan and insurer if the managed care plan's certification is revoked. The managed care plan may reapply for certification as specified in the order of revocation. Upon suspension of certification, the managed care plan may continue to provide services under contracts in effect if the commissioner determines injured employees will continue to receive necessary medical services under Minnesota Statutes, section 176.135.

Statutory Authority:

MS s 176.1351

History:

18 SR 1379

Published Electronically:

June 11, 2008