Subdivision 1. Scope. As used in sections 145.61 to 145.67 the terms defined in this section have the meanings given them.
Subd. 2. Professional. "Professional" means a person licensed or registered to practice a healing art under chapter 147 or 148, to practice dentistry under chapter 150A, to practice as a pharmacist under chapter 151, or to practice podiatry under chapter 153.
Subd. 3. Professional service. "Professional service" means service rendered by a professional of the type such professional is licensed to perform.
Subd. 4. Health care. "Health care" means professional services rendered by a professional or an employee of a professional and services furnished by a hospital, sanitarium, nursing home or other institution for the hospitalization or care of human beings.
Subd. 4a. Administrative staff. "Administrative staff" means the staff of a hospital, clinic, nursing home, nonprofit health service plan corporation, or health maintenance organization.
Subd. 4b. Consumer Director. "Consumer director" means a director of a health service plan corporation or health maintenance organization who is not a licensed or registered health care professional.
Subd. 4c. Preferred provider organization. "Preferred provider organization" means an organization that contracts with insurance carriers or other entities to arrange a network of health care providers whose services are offered to the insureds or other covered persons.
Subd. 5. Review organization. "Review organization" means a nonprofit organization acting according to clause (k), a committee as defined under section 144E.32, subdivision 2, or a committee whose membership is limited to professionals, administrative staff, and consumer directors, except where otherwise provided for by state or federal law, and which is established by one or more of the following: a hospital, a clinic, a nursing home, an ambulance service or first responder service regulated under chapter 144E, one or more state or local associations of professionals, an organization of professionals from a particular area or medical institution, a health maintenance organization as defined in chapter 62D, a community integrated service network as defined in chapter 62N, a nonprofit health service plan corporation as defined in chapter 62C, a preferred provider organization, a professional standards review organization established pursuant to United States Code, title 42, section 1320c-1 et seq., a medical review agent established to meet the requirements of section 256B.04, subdivision 15, or 256D.03, subdivision 7, paragraph (b), the department of human services, a health provider cooperative operating under sections 62R.17 to 62R.26, or a corporation organized under chapter 317A that owns, operates, or is established by one or more of the above referenced entities, to gather and review information relating to the care and treatment of patients for the purposes of:
(a) evaluating and improving the quality of health care rendered in the area or medical institution or by the entity or organization that established the review organization;
(b) reducing morbidity or mortality;
(c) obtaining and disseminating statistics and information relative to the treatment and prevention of diseases, illness and injuries;
(d) developing and publishing guidelines showing the norms of health care in the area or medical institution or in the entity or organization that established the review organization;
(e) developing and publishing guidelines designed to keep within reasonable bounds the cost of health care;
(f) reviewing the quality or cost of health care services provided to enrollees of health maintenance organizations, community integrated service networks, health service plans, preferred provider organizations, and insurance companies;
(g) acting as a professional standards review organization pursuant to United States Code, title 42, section 1320c-1 et seq.;
(h) determining whether a professional shall be granted staff privileges in a medical institution, membership in a state or local association of professionals, or participating status in a nonprofit health service plan corporation, health maintenance organization, community integrated service network, preferred provider organization, or insurance company, or whether a professional's staff privileges, membership, or participation status should be limited, suspended or revoked;
(i) reviewing, ruling on, or advising on controversies, disputes or questions between:
(1) health insurance carriers, nonprofit health service plan corporations, health maintenance organizations, community integrated service networks, self-insurers and their insureds, subscribers, enrollees, or other covered persons;
(2) professional licensing boards and health providers licensed by them;
(3) professionals and their patients concerning diagnosis, treatment or care, or the charges or fees therefor;
(4) professionals and health insurance carriers, nonprofit health service plan corporations, health maintenance organizations, community integrated service networks, or self-insurers concerning a charge or fee for health care services provided to an insured, subscriber, enrollee, or other covered person;
(5) professionals or their patients and the federal, state, or local government, or agencies thereof;
(j) providing underwriting assistance in connection with professional liability insurance coverage applied for or obtained by dentists, or providing assistance to underwriters in evaluating claims against dentists;
(l) providing recommendations on the medical necessity of a health service, or the relevant prevailing community standard for a health service;
(m) providing quality assurance as required by United States Code, title 42, sections 1396r(b)(1)(b) and 1395i-3(b)(1)(b) of the Social Security Act;
(n) providing information to group purchasers of health care services when that information was originally generated within the review organization for a purpose specified by this subdivision; or
(o) providing information to other, affiliated or nonaffiliated review organizations, when that information was originally generated within the review organization for a purpose specified by this subdivision, and as long as that information will further the purposes of a review organization as specified by this subdivision.
HIST: 1971 c 283 s 1; 1974 c 295 s 1,2; 1975 c 73 s 1; 1976 c 173 s 49; 1982 c 424 s 133; 1982 c 546 s 1; 1985 c 184 s 1; 1989 c 282 art 3 s 30; 1991 c 137 s 1-3; 1992 c 400 s 1,2; 1992 c 549 art 7 s 6; 1993 c 345 art 3 s 18; 1994 c 497 s 1,2; 1996 c 305 art 1 s 37; 1996 c 451 art 4 s 24; 1999 c 51 s 2; 1999 c 84 s 2
Official Publication of the State of Minnesota
Revisor of Statutes