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, a provider, and the commissioner of commerce the criteria used to
determine the medical necessity, appropriateness, and efficacy of a procedure or service and
identify the database, professional treatment guideline, or other basis for the criteria.
History: 1992 c 574 s 10; 1995 c 234 art 8 s 14; 1999 c 239 s 27-29; 2001 c 137 s 6