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62M.10 Accessibility and on-site review procedures.

Subdivision 1. Toll-free number. A utilization review organization must provide access to its review staff by a toll-free or collect call telephone line during normal business hours. A utilization review organization must also have an established procedure to receive timely callbacks from providers and must establish written procedures for receiving after-hour calls, either in person or by recording.

Subd. 2. Reviews during normal business hours. A utilization review organization must conduct its telephone reviews, on-site reviews, and hospital communications during reasonable and normal business hours, unless otherwise mutually agreed.

Subd. 3. Identification of on-site review staff. Each utilization review organization's staff must identify themselves by name and by the name of their organization and, for on-site reviews, must carry picture identification and the utilization review organization's company identification card. On-site reviews should, whenever possible, be scheduled at least one business day in advance with the appropriate hospital contact. If requested by a hospital or inpatient facility, utilization review organizations must ensure that their on-site review staff register with the appropriate contact person, if available, prior to requesting any clinical information or assistance from hospital staff. The on-site review staff must wear appropriate hospital supplied identification tags while on the premises.

Subd. 4. On-site reviews. Utilization review organizations must agree, if requested, that the medical records remain available in designated areas during the on-site review and that reasonable hospital administrative procedures must be followed by on-site review staff so as to not disrupt hospital operations or patient care. Such procedures, however, must not limit the ability of the utilization review organizations to efficiently conduct the necessary review on behalf of the patient's health benefit plan.

Subd. 5. Oral requests for information. Utilization review organizations shall orally inform, upon request, designated hospital personnel or the attending health care professional of the utilization review requirements of the specific health benefit plan and the general type of criteria used by the review agent. Utilization review organizations should also orally inform, upon request, a provider of the operational procedures in order to facilitate the review process.

Subd. 6. Mutual agreement. Nothing in this section limits the ability of a utilization review organization and a provider to mutually agree in writing on how review should be conducted.

Subd. 7. Availability of criteria. Upon request, a utilization review organization shall provide to an enrollee or to a provider the criteria used for a specific procedure to determine the necessity, appropriateness, and efficacy of that procedure and identify the database, professional treatment guideline, or other basis for the criteria.

HIST: 1992 c 574 s 10; 1995 c 234 art 8 s 14; 1999 c 239 s 27-29

* NOTE: The amendments to subdivisions 2, 5, and 7 by Laws *1999, chapter 239, sections 27 to 29, are 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.