1997 Minnesota Statutes

     62M.02 Definitions. 

    Subdivision 1.    Terms.  For the purposes of sections 
 62M.01 to 62M.16, the terms defined in this section have the 
 meanings given them. 

    Subd. 2.    Appeal.  "Appeal" means a formal request, 
 either orally or in writing, to reconsider a determination not 
 to certify an admission, extension of stay, or other health care 
 service. 

    Subd. 3.    Attending dentist.  "Attending dentist" 
 means the dentist with primary responsibility for the dental 
 care provided to a patient. 

    Subd. 4.    Attending physician.  "Attending physician" 
 means the physician with primary responsibility for the care 
 provided to a patient in a hospital or other health care 
 facility. 

    Subd. 5.    Certification.  "Certification" means a 
 determination by a utilization review organization that an 
 admission, extension of stay, or other health care service has 
 been reviewed and that it, based on the information provided, 
 meets the utilization review requirements of the applicable 
 health plan and the health carrier will then pay for the covered 
 benefit, provided the preexisting limitation provisions, the 
 general exclusion provisions, and any deductible, copayment, 
 coinsurance, or other policy requirements have been met. 

    Subd. 6.    Claims administrator.  "Claims administrator"
 means an entity that reviews and determines whether to pay 
 claims to enrollees, physicians, hospitals, or others based on 
 the contract provisions of the health plan contract.  Claims 
 administrators may include insurance companies licensed under 
 chapter 60A to offer, sell, or issue a policy of accident and 
 sickness insurance as defined in section 62A.01; a health 
 service plan licensed under chapter 62C; a health maintenance 
 organization licensed under chapter 62D; a fraternal benefit 
 society operating under chapter 64B; a multiple employer welfare 
 arrangement, as defined in section 3 of the Employee Retirement 
 Income Security Act of 1974 (ERISA), United States Code, title 
 29, section 1103, as amended. 

    Subd. 7.    Claimant.  "Claimant" means the enrollee or 
 covered person who files a claim for benefits or a provider of 
 services who, pursuant to a contract with a claims 
 administrator, files a claim on behalf of an enrollee or covered 
 person. 

    Subd. 8.    Clinical criteria.  "Clinical criteria" 
 means the written policies, decision rules, medical protocols, 
 or guidelines used by the utilization review organization to 
 determine certification. 

    Subd. 9.    Concurrent review.  "Concurrent review" 
 means utilization review conducted during a patient's hospital 
 stay or course of treatment and has the same meaning as 
 continued stay review. 

    Subd. 10.    Discharge planning.  "Discharge planning" 
 means the process that assesses a patient's need for treatment 
 after hospitalization in order to help arrange for the necessary 
 services and resources to effect an appropriate and timely 
 discharge. 

    Subd. 11.    Enrollee.  "Enrollee" means an individual 
 who has elected to contract for, or participate in, a health 
 benefit plan for enrollee coverage or for dependent coverage. 

    Subd. 12.    Health benefit plan.  "Health benefit plan" 
 means a policy, contract, or certificate issued by a health 
 carrier to an employer or individual for the coverage of 
 medical, dental, or hospital benefits.  A health benefit plan 
 does not include coverage that is: 

    (1) limited to disability or income protection coverage; 

    (2) automobile medical payment coverage; 

    (3) supplemental to liability insurance; 

    (4) designed solely to provide payments on a per diem, 
 fixed indemnity, or nonexpense incurred basis; 

    (5) credit accident and health insurance issued under 
 chapter 62B; 

    (6) blanket accident and sickness insurance as defined in 
 section 62A.11; 

    (7) accident only coverage issued by a licensed and tested 
 insurance agent; or 

    (8) workers' compensation. 

    Subd. 13.    Inpatient admissions to hospitals.  
 "Inpatient admissions to hospitals" includes admissions to all 
 acute medical, surgical, obstetrical, psychiatric, and chemical 
 dependency inpatient services at a licensed hospital facility, 
 as well as other licensed inpatient facilities including skilled 
 nursing facilities, residential treatment centers, and free 
 standing rehabilitation facilities. 

    Subd. 14.    Outpatient services.  "Outpatient services" 
 means procedures or services performed on a basis other than as 
 an inpatient, and includes obstetrical, psychiatric, chemical 
 dependency, dental, and chiropractic services. 

    Subd. 15.    Prior authorization.  "Prior authorization" 
 means utilization review conducted prior to the delivery of a 
 service, including an outpatient service. 

    Subd. 16.    Prospective review.  "Prospective review" 
 means utilization review conducted prior to an enrollee's 
 inpatient stay. 

    Subd. 17.    Provider.  "Provider" means a licensed 
 health care facility, physician, or other health care 
 professional that delivers health care services to an enrollee 
 or covered person. 

    Subd. 18.    Quality assessment program.  "Quality 
 assessment program" means a structured mechanism that monitors 
 and evaluates a utilization review organization's program and 
 provides management intervention to support compliance with the 
 requirements of this chapter. 

    Subd. 19.    Reconsideration request.  "Reconsideration 
 request" means an initial request by telephone for additional 
 review of a utilization review organization's determination not 
 to certify an admission, extension of stay, or other health care 
 service. 

    Subd. 20.    Utilization review.  "Utilization review" 
 means the evaluation of the necessity, appropriateness, and 
 efficacy of the use of health care services, procedures, and 
 facilities, by a person or entity other than the attending 
 physician, for the purpose of determining the medical necessity 
 of the service or admission.  Utilization review also includes 
 review conducted after the admission of the enrollee.  It 
 includes situations where the enrollee is unconscious or 
 otherwise unable to provide advance notification.  Utilization 
 review does not include the imposition of a requirement that 
 services be received by or upon referral from a participating 
 provider. 

    Subd. 21.    Utilization review organization.  
 "Utilization review organization" means an entity including but 
 not limited to an insurance company licensed under chapter 60A 
 to offer, sell, or issue a policy of accident and sickness 
 insurance as defined in section 62A.01; a health service plan 
 licensed under chapter 62C; a health maintenance organization 
 licensed under chapter 62D; a community integrated service 
 network licensed under chapter 62N; a fraternal benefit society 
 operating under chapter 64B; a joint self-insurance employee 
 health plan operating under chapter 62H; a multiple employer 
 welfare arrangement, as defined in section 3 of the Employee 
 Retirement Income Security Act of 1974 (ERISA), United States 
 Code, title 29, section 1103, as amended; a third party 
 administrator licensed under section 60A.23, subdivision 8, 
 which conducts utilization review and determines certification 
 of an admission, extension of stay, or other health care 
 services for a Minnesota resident; or any entity performing 
 utilization review that is affiliated with, under contract with, 
 or conducting utilization review on behalf of, a business entity 
 in this state. 

    HIST: 1992 c 574 s 2; 1994 c 625 art 2 s 7,8; 1997 c 225 art 2 
 s 30