2006 Minnesota Statutes

CHAPTER 62M. UTILIZATION REVIEW OF HEALTH CARE

62M.01 CITATION, JURISDICTION, AND SCOPE.
    Subdivision 1. Popular name. Sections 62M.01 to 62M.16 may be cited as the "Minnesota
Utilization Review Act of 1992."
    Subd. 2. Jurisdiction. Sections 62M.01 to 62M.16 apply to any insurance company licensed
under chapter 60A to offer, sell, or issue a policy of accident and sickness insurance as defined
in section 62A.01; a health service plan licensed under chapter 62C; a health maintenance
organization licensed under chapter 62D; the Minnesota Comprehensive Health Association
created under chapter 62E; 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, that provides utilization
review services for the administration of benefits under a health benefit plan as defined in section
62M.02; or any entity performing utilization review on behalf of a business entity in this state
pursuant to a health benefit plan covering a Minnesota resident.
    Subd. 3. Scope. Nothing in sections 62M.01 to 62M.16 applies to review of claims
after submission to determine eligibility for benefits under a health benefit plan. The appeal
procedure described in section 62M.06 applies to any complaint as defined under section 62Q.68,
subdivision 2 , that requires a medical determination in its resolution.
History: 1992 c 574 s 1; 1999 c 239 s 3; 2006 c 255 s 31

62M.02 DEFINITIONS.
    Subdivision 1. Terms. For the purposes of sections 62M.01 to 62M.16, 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, or 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
62A.01; 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
certification.
    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
stay review.
    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
certificate holder.
    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
incurred basis;
(5) credit accident and health insurance issued under chapter 62B;
(6) blanket accident and sickness insurance as defined in section 62A.11;
(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
facilities.
    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 62A.01; 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

62M.03 COMPLIANCE WITH STANDARDS.
    Subdivision 1. Licensed utilization review organization. Beginning January 1, 1993,
any organization that meets the definition of utilization review organization in section 62M.02,
subdivision 21 , must be licensed under chapter 60A, 62C, 62D, 62N, 62T, or 64B, or registered
under this chapter and must comply with sections 62M.01 to 62M.16 and section 72A.201,
subdivisions 8 and 8a . Each licensed community integrated service network or health maintenance
organization that has an employed staff model of providing health care services shall comply
with sections 62M.01 to 62M.16 and section 72A.201, subdivisions 8 and 8a, for any services
provided by providers under contract.
    Subd. 2. Nonlicensed utilization review organization. An organization that meets the
definition of a utilization review organization under section 62M.02, subdivision 21, that is
not licensed in this state that performs utilization review services for Minnesota residents must
register with the commissioner of commerce and must certify compliance with sections 62M.01
to 62M.16.
Initial registration must occur no later than January 1, 1993. The registration is effective for
two years and may be renewed. Applications for initial and renewal registrations must be made on
forms prescribed by the commissioner. Each utilization review organization registered under this
chapter shall notify the commissioner of commerce within 30 days of any change in the name,
address, or ownership of the organization. The organization shall pay to the commissioner of
commerce a fee of $1,000 for the initial registration application and $1,000 for each two-year
renewal.
    Subd. 3. Penalties and enforcements. If a utilization review organization fails to comply
with sections 62M.01 to 62M.16, the organization may not provide utilization review services
for any Minnesota resident. The commissioner of commerce may issue a cease and desist order
under section 45.027, subdivision 5, to enforce this provision. The cease and desist order is
subject to appeal under chapter 14. A nonlicensed utilization review organization that fails to
comply with the provisions of sections 62M.01 to 62M.16 is subject to all applicable penalty
and enforcement provisions of section 72A.201. Each utilization review organization licensed
under chapter 60A, 62C, 62D, 62N, 62T, or 64B shall comply with sections 62M.01 to 62M.16
as a condition of licensure.
History: 1992 c 574 s 3; 1994 c 625 art 2 s 9-11; 1997 c 225 art 2 s 62; 1999 c 239 s 17,18;
2001 c 215 s 24; 2002 c 330 s 27

62M.04 STANDARDS FOR UTILIZATION REVIEW PERFORMANCE.
    Subdivision 1. Responsibility for obtaining certification. A health benefit plan that
includes utilization review requirements must specify the process for notifying the utilization
review organization in a timely manner and obtaining certification for health care services. Each
health plan company must provide a clear and concise description of this process to an enrollee as
part of the policy, subscriber contract, or certificate of coverage. In addition to the enrollee, the
utilization review organization must allow any provider or provider's designee, or responsible
patient representative, including a family member, to fulfill the obligations under the health plan.
A claims administrator that contracts directly with providers for the provision of health care
services to enrollees may, through contract, require the provider to notify the review organization
in a timely manner and obtain certification for health care services.
    Subd. 2. Information upon which utilization review is conducted. If the utilization review
organization is conducting routine prospective and concurrent utilization review, utilization
review organizations must collect only the information necessary to certify the admission,
procedure of treatment, and length of stay.
(a) Utilization review organizations may request, but may not require providers to supply
numerically encoded diagnoses or procedures as part of the certification process.
(b) Utilization review organizations must not routinely request copies of medical records for
all patients reviewed. In performing prospective and concurrent review, copies of the pertinent
portion of the medical record should be required only when a difficulty develops in certifying the
medical necessity or appropriateness of the admission or extension of stay.
(c) Utilization review organizations may request copies of medical records retrospectively
for a number of purposes, including auditing the services provided, quality assurance review,
ensuring compliance with the terms of either the health benefit plan or the provider contract, and
compliance with utilization review activities. Except for reviewing medical records associated
with an appeal or with an investigation or audit of data discrepancies, providers must be
reimbursed for the reasonable costs of duplicating records requested by the utilization review
organization for retrospective review unless otherwise provided under the terms of the provider
contract.
    Subd. 3. Data elements. Except as otherwise provided in sections 62M.01 to 62M.16, for
purposes of certification a utilization review organization must limit its data requirements to the
following elements:
(a) Patient information that includes the following:
(1) name;
(2) address;
(3) date of birth;
(4) sex;
(5) Social Security number or patient identification number;
(6) name of health plan company or health plan; and
(7) plan identification number.
(b) Enrollee information that includes the following:
(1) name;
(2) address;
(3) Social Security number or employee identification number;
(4) relation to patient;
(5) employer;
(6) health benefit plan;
(7) group number or plan identification number; and
(8) availability of other coverage.
(c) Attending health care professional information that includes the following:
(1) name;
(2) address;
(3) telephone numbers;
(4) degree and license;
(5) specialty or board certification status; and
(6) tax identification number or other identification number.
(d) Diagnosis and treatment information that includes the following:
(1) primary diagnosis with associated ICD or DSM coding, if available;
(2) secondary diagnosis with associated ICD or DSM coding, if available;
(3) tertiary diagnoses with associated ICD or DSM coding, if available;
(4) proposed procedures or treatments with ICD or associated CPT codes, if available;
(5) surgical assistant requirement;
(6) anesthesia requirement;
(7) proposed admission or service dates;
(8) proposed procedure date; and
(9) proposed length of stay.
(e) Clinical information that includes the following:
(1) support and documentation of appropriateness and level of service proposed; and
(2) identification of contact person for detailed clinical information.
(f) Facility information that includes the following:
(1) type;
(2) licensure and certification status and DRG exempt status;
(3) name;
(4) address;
(5) telephone number; and
(6) tax identification number or other identification number.
(g) Concurrent or continued stay review information that includes the following:
(1) additional days, services, or procedures proposed;
(2) reasons for extension, including clinical information sufficient for support of
appropriateness and level of service proposed; and
(3) diagnosis status.
(h) For admissions to facilities other than acute medical or surgical hospitals, additional
information that includes the following:
(1) history of present illness;
(2) patient treatment plan and goals;
(3) prognosis;
(4) staff qualifications; and
(5) 24-hour availability of staff.
Additional information may be required for other specific review functions such as discharge
planning or catastrophic case management. Second opinion information may also be required,
when applicable, to support benefit plan requirements.
    Subd. 4. Additional information. A utilization review organization may request information
in addition to that described in subdivision 3 when there is significant lack of agreement between
the utilization review organization and the provider regarding the appropriateness of certification
during the review or appeal process. For purposes of this subdivision, "significant lack of
agreement" means that the utilization review organization has:
(1) tentatively determined through its professional staff that a service cannot be certified;
(2) referred the case to a physician for review; and
(3) talked to or attempted to talk to the attending health care professional for further
information.
Nothing in sections 62M.01 to 62M.16 prohibits a utilization review organization from
requiring submission of data necessary to comply with the quality assurance and utilization
review requirements of chapter 62D or other appropriate data or outcome analyses.
    Subd. 5. Sharing of information. To the extent allowed under sections 72A.49 to 72A.505,
a utilization review organization shall share all available clinical and demographic information
on individual patients internally to avoid duplicate requests for information from enrollees or
providers.
History: 1992 c 574 s 4; 1999 c 239 s 19-22

62M.05 PROCEDURES FOR REVIEW DETERMINATION.
    Subdivision 1. Written procedures. A utilization review organization must have written
procedures to ensure that reviews are conducted in accordance with the requirements of this
chapter.
    Subd. 2. Concurrent review. A utilization review organization may review ongoing inpatient
stays based on the severity or complexity of the enrollee's condition or on necessary treatment or
discharge planning activities. Such review must not be consistently conducted on a daily basis.
    Subd. 3. Notification of determinations. A utilization review organization must have
written procedures for providing notification of its determinations on all certifications in
accordance with this section.
    Subd. 3a. Standard review determination. (a) Notwithstanding subdivision 3b, an initial
determination on all requests for utilization review must be communicated to the provider and
enrollee in accordance with this subdivision within ten business days of the request, provided
that all information reasonably necessary to make a determination on the request has been made
available to the utilization review organization.
(b) When an initial determination is made to certify, notification must be provided promptly
by telephone to the provider. The utilization review organization shall send written notification to
the provider or shall maintain an audit trail of the determination and telephone notification. For
purposes of this subdivision, "audit trail" includes documentation of the telephone notification,
including the date; the name of the person spoken to; the enrollee; the service, procedure, or
admission certified; and the date of the service, procedure, or admission. If the utilization
review organization indicates certification by use of a number, the number must be called the
"certification number."
(c) When an initial determination is made not to certify, notification must be provided by
telephone within one working day after making the determination to the attending health care
professional and hospital and a written notification must be sent to the hospital, attending health
care professional, and enrollee. The written notification must include the principal reason or
reasons for the determination and the process for initiating an appeal of the determination. Upon
request, the utilization review organization shall provide the provider or enrollee with the criteria
used to determine the necessity, appropriateness, and efficacy of the health care service and
identify the database, professional treatment parameter, or other basis for the criteria. Reasons for
a determination not to certify may include, among other things, the lack of adequate information
to certify after a reasonable attempt has been made to contact the provider or enrollee.
(d) When an initial determination is made not to certify, the written notification must
inform the enrollee and the attending health care professional of the right to submit an appeal
to the internal appeal process described in section 62M.06 and the procedure for initiating the
internal appeal.
    Subd. 3b. Expedited review determination. (a) An expedited initial determination must
be utilized if the attending health care professional believes that an expedited determination is
warranted.
(b) Notification of an expedited initial determination to either certify or not to certify must be
provided to the hospital, the attending health care professional, and the enrollee as expeditiously
as the enrollee's medical condition requires, but no later than 72 hours from the initial request.
When an expedited initial determination is made not to certify, the utilization review organization
must also notify the enrollee and the attending health care professional of the right to submit an
appeal to the expedited internal appeal as described in section 62M.06 and the procedure for
initiating an internal expedited appeal.
    Subd. 4. Failure to provide necessary information. A utilization review organization must
have written procedures to address the failure of a provider or enrollee to provide the necessary
information for review. If the enrollee or provider will not release the necessary information to
the utilization review organization, the utilization review organization may deny certification in
accordance with its own policy or the policy described in the health benefit plan.
    Subd. 5. Notification to claims administrator. If the utilization review organization and
the claims administrator are separate entities, the utilization review organization must forward,
electronically or in writing, a notification of certification or determination not to certify to the
appropriate claims administrator for the health benefit plan. If it is determined by the claims
administrator that the certified health care service is not covered by the health benefit plan, the
claims administrator must promptly notify the claimant and provider of this information.
History: 1992 c 574 s 5; 1994 c 485 s 65; 1994 c 625 art 2 s 12; 1999 c 239 s 23; 2001
c 215 s 25

62M.06 APPEALS OF DETERMINATIONS NOT TO CERTIFY.
    Subdivision 1. Procedures for appeal. A utilization review organization must have written
procedures for appeals of determinations not to certify. The right to appeal must be available to
the enrollee and to the attending health care professional.
    Subd. 2. Expedited appeal. (a) When an initial determination not to certify a health care
service is made prior to or during an ongoing service requiring review and the attending health
care professional believes that the determination warrants an expedited appeal, the utilization
review organization must ensure that the enrollee and the attending health care professional have
an opportunity to appeal the determination over the telephone on an expedited basis. In such
an appeal, the utilization review organization must ensure reasonable access to its consulting
physician or health care provider.
(b) The utilization review organization shall notify the enrollee and attending health care
professional by telephone of its determination on the expedited appeal as expeditiously as the
enrollee's medical condition requires, but no later than 72 hours after receiving the expedited
appeal.
(c) If the determination not to certify is not reversed through the expedited appeal, the
utilization review organization must include in its notification the right to submit the appeal to
the external appeal process described in section 62Q.73 and the procedure for initiating the
process. This information must be provided in writing to the enrollee and the attending health
care professional as soon as practical.
    Subd. 3. Standard appeal. The utilization review organization must establish procedures for
appeals to be made either in writing or by telephone.
(a) A utilization review organization shall notify in writing the enrollee, attending health care
professional, and claims administrator of its determination on the appeal within 30 days upon
receipt of the notice of appeal. If the utilization review organization cannot make a determination
within 30 days due to circumstances outside the control of the utilization review organization, the
utilization review organization may take up to 14 additional days to notify the enrollee, attending
health care professional, and claims administrator of its determination. If the utilization review
organization takes any additional days beyond the initial 30-day period to make its determination,
it must inform the enrollee, attending health care professional, and claims administrator, in
advance, of the extension and the reasons for the extension.
(b) The documentation required by the utilization review organization may include copies of
part or all of the medical record and a written statement from the attending health care professional.
(c) Prior to upholding the initial determination not to certify for clinical reasons, the
utilization review organization shall conduct a review of the documentation by a physician who
did not make the initial determination not to certify.
(d) The process established by a utilization review organization may include defining a period
within which an appeal must be filed to be considered. The time period must be communicated to
the enrollee and attending health care professional when the initial determination is made.
(e) An attending health care professional or enrollee who has been unsuccessful in an attempt
to reverse a determination not to certify shall, consistent with section 72A.285, be provided
the following:
(1) a complete summary of the review findings;
(2) qualifications of the reviewers, including any license, certification, or specialty
designation; and
(3) the relationship between the enrollee's diagnosis and the review criteria used as the basis
for the decision, including the specific rationale for the reviewer's decision.
(f) In cases of appeal to reverse a determination not to certify for clinical reasons, the
utilization review organization must ensure that a physician of the utilization review organization's
choice in the same or a similar specialty as typically manages the medical condition, procedure, or
treatment under discussion is reasonably available to review the case.
(g) If the initial determination is not reversed on appeal, the utilization review organization
must include in its notification the right to submit the appeal to the external review process
described in section 62Q.73 and the procedure for initiating the external process.
    Subd. 4. Notification to claims administrator. If the utilization review organization and the
claims administrator are separate entities, the utilization review organization must notify, either
electronically or in writing, the appropriate claims administrator for the health benefit plan of any
determination not to certify that is reversed on appeal.
History: 1992 c 574 s 6; 1994 c 625 art 2 s 13; 1999 c 239 s 24; 2001 c 137 s 1

62M.07 PRIOR AUTHORIZATION OF SERVICES.
(a) Utilization review organizations conducting prior authorization of services must have
written standards that meet at a minimum the following requirements:
(1) written procedures and criteria used to determine whether care is appropriate, reasonable,
or medically necessary;
(2) a system for providing prompt notification of its determinations to enrollees and
providers and for notifying the provider, enrollee, or enrollee's designee of appeal procedures
under clause (4);
(3) compliance with section 62M.05, subdivisions 3a and 3b, regarding time frames for
approving and disapproving prior authorization requests;
(4) written procedures for appeals of denials of prior authorization which specify the
responsibilities of the enrollee and provider, and which meet the requirements of sections 62M.06
and 72A.285, regarding release of summary review findings; and
(5) procedures to ensure confidentiality of patient-specific information, consistent with
applicable law.
(b) No utilization review organization, health plan company, or claims administrator may
conduct or require prior authorization of emergency confinement or emergency treatment. The
enrollee or the enrollee's authorized representative may be required to notify the health plan
company, claims administrator, or utilization review organization as soon after the beginning of
the emergency confinement or emergency treatment as reasonably possible.
(c) If prior authorization for a health care service is required, the utilization review
organization, health plan company, or claim administrator must allow providers to submit requests
for prior authorization of the health care services without unreasonable delay by telephone,
facsimile, or voice mail or through an electronic mechanism 24 hours a day, seven days a week.
This paragraph does not apply to dental service covered under MinnesotaCare, general assistance
medical care, or medical assistance.
History: 1992 c 574 s 7; 1994 c 485 s 65; 1995 c 234 art 8 s 12; 1999 c 239 s 25; 2004
c 246 s 1

62M.072 USE OF EVIDENCE-BASED STANDARDS.
If no independently developed evidence-based standards exist for a particular treatment,
testing, or imaging procedure, then an insurer or utilization review organization shall not deny
coverage of the treatment, testing, or imaging based solely on the grounds that the treatment,
testing, or imaging does not meet an evidence-based standard. This section does not prohibit
an insurer or utilization review organization from denying coverage for services that are
investigational, experimental, or not medically necessary.
History: 2006 c 255 s 32

62M.08 CONFIDENTIALITY.
    Subdivision 1. Written procedures to ensure confidentiality. A utilization review
organization must have written procedures for ensuring that patient-specific information obtained
during the process of utilization review will be:
(1) kept confidential in accordance with applicable federal and state laws;
(2) used solely for the purposes of utilization review, quality assurance, discharge planning,
and case management; and
(3) shared only with those organizations or persons that have the authority to receive such
information.
    Subd. 2. Summary data. Summary data is not subject to this section if it does not provide
sufficient information to allow identification of individual patients.
History: 1992 c 574 s 8

62M.09 STAFF AND PROGRAM QUALIFICATIONS; ANNUAL REPORT.
    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) 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.
(b) The physician conducting the review must be licensed in this state. This paragraph does
not apply to reviews conducted in connection with policies issued by a health plan company that
is assessed less than three percent of the total amount assessed by the Minnesota Comprehensive
Health Association.
(c) The physician should be reasonably available by telephone to discuss the determination
with the attending health care professional.
(d) 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 this state. 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. This
subdivision does not apply to determinations made in connection with policies issued by a
health plan company that is assessed less than three percent of the total amount assessed by the
Minnesota Comprehensive Health Association.
    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 must be board certified 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.
    Subd. 9. Annual report. A utilization review organization shall file an annual report with the
annual financial statement it submits to the commissioner of commerce that includes:
(1) per 1,000 utilization reviews, the number and rate of determinations not to certify based
on medical necessity for each procedure or service; and
(2) the number and rate of denials overturned on appeal.
A utilization review organization that is not a licensed health carrier must submit the annual
report required by this subdivision on April 1 of each year.
History: 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; 2001 c 137 s 2-5; 2006 c 255 s 33

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

62M.11 COMPLAINTS TO COMMERCE OR HEALTH.
Notwithstanding the provisions of sections 62M.01 to 62M.16, an enrollee may file a
complaint regarding a determination not to certify directly to the commissioner responsible for
regulating the utilization review organization.
History: 1992 c 574 s 11

62M.12 PROHIBITION OF INAPPROPRIATE INCENTIVES.
No individual who is performing utilization review may receive any financial incentive
based on the number of denials of certifications made by such individual, provided that utilization
review organizations may establish medically appropriate performance standards. This prohibition
does not apply to financial incentives established between health plan companies and providers.
History: 1992 c 574 s 12; 1999 c 239 s 30

62M.13 SEVERABILITY.
If any provisions of sections 62M.01 to 62M.16 are held invalid, illegal, or unenforceable
for any reason and in any respect, the holding does not affect the validity of the remainder of
sections 62M.01 to 62M.16.
History: 1992 c 574 s 13

62M.14 EFFECT OF COMPLIANCE.
Evidence of a utilization review organization's compliance or noncompliance with the
provisions of sections 62M.01 to 62M.16 shall not be determinative in an action alleging that
services denied were medically necessary and covered under the terms of the enrollee's health
benefit plan.
History: 1992 c 574 s 14

62M.15 APPLICABILITY OF OTHER CHAPTER REQUIREMENTS.
The requirements of this chapter regarding the conduct of utilization review are in addition
to any specific requirements contained in chapter 62A, 62C, 62D, 62Q, 62T, or 72A.
History: 1992 c 574 s 15; 1999 c 239 s 31

62M.16 RULEMAKING.
If it is determined that rules are reasonable and necessary to accomplish the purpose of
sections 62M.01 to 62M.16, the rules must be adopted through a joint rulemaking process by both
the Department of Commerce and the Department of Health.
History: 1992 c 574 s 16