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Minnesota Legislature

Office of the Revisor of 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 health care professional. 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; 1999 c 239 s 26

* NOTE: The amendment to subdivision 3 by Laws 1999, chapter *239, section 26, is effective April 1, 2000, and applies to *contracts issued or renewed on or after that date. Upon *request, the commissioner of health or commerce shall grant an *extension of up to three months to any health plan company or *utilization review organization that is unable to comply with *Laws 1999, chapter 239, sections 1, 3 to 42, and 43, paragraphs *(a) and (c) by April 1, 2000, due to circumstances beyond the *control of the health plan company or utilization review *organization. Laws 1999, chapter 239, section 44.