Minnesota Administrative Rules

9505.5082 NOTICE ABOUT DETERMINATION OF MEDICAL APPROPRIATENESS.

Subpart 1.

Notice approving authorization number.

If a surgical procedure requiring a second medical opinion is determined to be medically appropriate and the medical review agent issues an authorization number for the surgical procedure, the medical review agent must inform, by telephone, the physician requesting the procedure and mail the recipient and the physician a notice of the determination within 24 hours of the determination, exclusive of weekends and holidays.

Subp. 2.

Notice denying authorization number.

If a surgical procedure requiring a second medical opinion is determined not to be medically appropriate or a decision about whether the surgical procedure is medically appropriate cannot be reached, the medical review agent shall deny an authorization number for the surgical procedure and notify by telephone within 24 hours of the denial the physician requesting the procedure. Additionally, the medical review agent must mail written notices as specified in items A to D within 24 hours of the denial or failure to reach a decision, exclusive of weekends and holidays.

A.

A notice to a recipient must state that the recipient may appeal the denial of the service under part 9505.5105 and Minnesota Statutes, section 256.045.

B.

A notice to a physician must state the reason for the denial of the authorization number. Additionally, the notice must state that, as appropriate, the physician may request the opinion of a physician adviser under part 9505.5077, subpart 1, a second physician adviser under part 9505.5077, subpart 2, or a reconsideration under part 9505.5078. The notice must also state that the admitting physician who requests the opinion of a physician adviser or a second physician adviser, as appropriate, may submit additional information to document the medical appropriateness of the surgical procedure.

C.

If on reconsideration a determination is made that the surgical procedure is not medically appropriate, notice to the physician must state the reason for the denial and must state that if the surgery has already been provided, the physician may appeal the denial under the contested case procedure under Minnesota Statutes, chapter 14, unless another procedure is required by statute. The notice must also state that the physician who appeals may submit additional information to document the medical appropriateness of the surgical procedure.

D.

If the medical review agent withdraws an authorization number under part 9505.5076, subpart 3, the notice must state the reason for the withdrawal and must state that the physician may request the opinion of a physician adviser under part 9505.5077.

Statutory Authority:

MS s 256.0625; 256.991; 256D.03

History:

20 SR 2405

Published Electronically:

August 12, 2008