Subdivision 1. Terms.
For the purposes of sections
, 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 an enrollee.
Subd. 4. Attending health care professional.
"Attending health care professional" means
the health care professional providing care within the scope of the professional's practice and with
primary responsibility for the care provided to an enrollee. Attending health care professional shall
include only physicians; chiropractors; dentists; mental health professionals as defined in section
245.462, subdivision 18
245.4871, subdivision 27
; podiatrists; and advanced practice nurses.
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 plan company will then pay for the covered benefit, provided
the preexisting limitation provisions, the general exclusion provisions, and any deductible,
co-payment, 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 or providers 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
; 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; an accountable provider network operating under chapter 62T; 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 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
Subd. 9. Concurrent review.
"Concurrent review" means utilization review conducted
during an enrollee's hospital stay or course of treatment and has the same meaning as continued
Subd. 10. Discharge planning.
"Discharge planning" means the process that assesses an
enrollee'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 covered by a health benefit plan and
includes an insured policyholder, subscriber, contract holder, member, covered person, or
Subd. 12. Health benefit plan.
"Health benefit plan" means a policy, contract, or certificate
issued by a health plan company 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
(5) credit accident and health insurance issued under chapter 62B;
(6) blanket accident and sickness insurance as defined in section
(7) accident only coverage issued by a licensed and tested insurance agent; or
(8) workers' compensation.
Subd. 12a. Health plan company.
"Health plan company" means a health plan company
as defined in section
62Q.01, subdivision 4
, and includes an accountable provider network
operating under chapter 62T.
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
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.
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 health care professional, 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 a referral or participation in a referral process by a participating provider unless the
provider is acting as a utilization review organization.
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
; 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; an accountable provider
network operating under chapter 62T; 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. Utilization review
organization does not include a clinic or health care system acting pursuant to a written delegation
agreement with an otherwise regulated utilization review organization that contracts with the
clinic or health care system. The regulated utilization review organization is accountable for the
delegated utilization review activities of the clinic or health care system.
History: 1992 c 574 s 2; 1994 c 625 art 2 s 7,8; 1997 c 225 art 2 s 30; 1999 c 239 s 4-16;
1Sp2001 c 9 art 16 s 5; 2002 c 379 art 1 s 113