1997 Minnesota Statutes

     62M.09 Staff and program qualifications. 

    Subdivision 1.    Staff criteria.  A utilization review 
 organization shall have utilization review staff who are 
 properly trained, qualified, and supervised. 

    Subd. 2.    Licensure requirement.  Nurses, physicians, 
 and other licensed health professionals conducting reviews of 
 medical services, and other clinical reviewers conducting 
 specialized reviews in their area of specialty must be currently 
 licensed or certified by an approved state licensing agency in 
 the United States. 

    Subd. 3.    Physician reviewer involvement.  A physician 
 must review all cases in which the utilization review 
 organization has concluded that a determination not to certify 
 for clinical reasons is appropriate.  The physician should be 
 reasonably available by telephone to discuss the determination 
 with the attending physician.  This subdivision does not apply 
 to outpatient mental health or substance abuse services governed 
 by subdivision 3a.  

    Subd. 3a.    Mental health and substance abuse reviews.  
 A peer of the treating mental health or substance abuse provider 
 or a physician must review requests for outpatient services in 
 which the utilization review organization has concluded that a 
 determination not to certify a mental health or substance abuse 
 service for clinical reasons is appropriate, provided that any 
 final determination not to certify treatment is made by a 
 psychiatrist certified by the American Board of Psychiatry and 
 Neurology and appropriately licensed in the state in which the 
 psychiatrist resides.  Notwithstanding the notification 
 requirements of section 62M.05, a utilization review 
 organization that has made an initial decision to certify in 
 accordance with the requirements of section 62M.05 may elect to 
 provide notification of a determination to continue coverage 
 through facsimile or mail. 

    Subd. 4.    Dentist plan reviews.  A dentist must review 
 all cases in which the utilization review organization has 
 concluded that a determination not to certify a dental service 
 or procedure for clinical reasons is appropriate and an appeal 
 has been made by the attending dentist, enrollee, or designee. 

    Subd. 4a.    Chiropractic review.  A chiropractor must 
 review all cases in which the utilization review organization 
 has concluded that a determination not to certify a chiropractic 
 service or procedure for clinical reasons is appropriate and an 
 appeal has been made by the attending chiropractor, enrollee, or 
 designee. 

    Subd. 5.    Written clinical criteria.  A utilization 
 review organization's decisions must be supported by written 
 clinical criteria and review procedures.  Clinical criteria and 
 review procedures must be established with appropriate 
 involvement from actively practicing physicians.  A utilization 
 review organization must use written clinical criteria, as 
 required, for determining the appropriateness of the 
 certification request.  The utilization review organization must 
 have a procedure for ensuring, at a minimum, the annual 
 evaluation and updating of the written criteria based on sound 
 clinical principles. 

    Subd. 6.    Physician consultants.  A utilization review 
 organization must use physician consultants in the appeal 
 process described in section 62M.06, subdivision 3.  The 
 physician consultants should include, as needed and available, 
 specialists who are board-certified, or board-eligible and 
 working towards certification, in a specialty board approved by 
 the American Board of Medical Specialists or the American Board 
 of Osteopathy. 

    Subd. 7.    Training for program staff.  A utilization 
 review organization must have a formalized program of 
 orientation and ongoing training of utilization review staff. 

    Subd. 8.    Quality assessment program.  A utilization 
 review organization must have written documentation of an active 
 quality assessment program. 

    HIST: 1992 c 574 s 9; 1993 c 99 s 1; 1995 c 234 art 8 s 13; 
 1996 c 305 art 1 s 24; 1997 c 140 s 1,2