2006 Minnesota Statutes

62Q.37 AUDITS CONDUCTED BY INDEPENDENT ORGANIZATION.
    Subdivision 1. Applicability. This section applies only to (i) a nonprofit health service plan
corporation operating under chapter 62C; (ii) a health maintenance organization operating under
chapter 62D; (iii) a community integrated service network operating under chapter 62N; and (iv)
managed care organizations operating under chapter 256B, 256D, or 256L.
    Subd. 2. Definitions. For purposes of this section, the following terms have the meanings
given them.
(a) "Commissioner" means the commissioner of health for purposes of regulating health
maintenance organizations and community integrated service networks, the commissioner
of commerce for purposes of regulating nonprofit health service plan corporations, or the
commissioner of human services for the purpose of contracting with managed care organizations
serving persons enrolled in programs under chapter 256B, 256D, or 256L.
(b) "Health plan company" means (i) a nonprofit health service plan corporation operating
under chapter 62C; (ii) a health maintenance organization operating under chapter 62D; (iii) a
community integrated service network operating under chapter 62N; or (iv) a managed care
organization operating under chapter 256B, 256D, or 256L.
(c) "Nationally recognized independent organization" means (i) an organization that sets
specific national standards governing health care quality assurance processes, utilization review,
provider credentialing, marketing, and other topics covered by this chapter and other chapters and
audits and provides accreditation to those health plan companies that meet those standards. The
American Accreditation Health Care Commission (URAC), the National Committee for Quality
Assurance (NCQA), and the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) are, at a minimum, defined as nationally recognized independent organizations; and (ii)
the Centers for Medicare and Medicaid Services for purposes of reviews or audits conducted of
health plan companies under Part C of Title XVIII of the Social Security Act or under section
1876 of the Social Security Act.
(d) "Performance standard" means those standards relating to quality management and
improvement, access and availability of service, utilization review, provider selection, provider
credentialing, marketing, member rights and responsibilities, complaints, appeals, grievance
systems, enrollee information and materials, enrollment and disenrollment, subcontractual
relationships and delegation, confidentiality, continuity and coordination of care, assurance of
adequate capacity and services, coverage and authorization of services, practice guidelines, health
information systems, and financial solvency.
    Subd. 3. Audits. (a) The commissioner may conduct routine audits and investigations
as prescribed under the commissioner's respective state authorizing statutes. If a nationally
recognized independent organization has conducted an audit of the health plan company
using audit procedures that are comparable to or more stringent than the commissioner's audit
procedures:
(1) the commissioner may accept the independent audit and require no further audit if the
results of the independent audit show that the performance standard being audited meets or
exceeds state standards;
(2) the commissioner may accept the independent audit and limit further auditing if the
results of the independent audit show that the performance standard being audited partially meets
state standards;
(3) the health plan company must demonstrate to the commissioner that the nationally
recognized independent organization that conducted the audit is qualified and that the results
of the audit demonstrate that the particular performance standard partially or fully meets state
standards; and
(4) if the commissioner has partially or fully accepted an independent audit of the
performance standard, the commissioner may use the finding of a deficiency with regard to
statutes or rules by an independent audit as the basis for a targeted audit or enforcement action.
(b) If a health plan company has formally delegated activities that are required under
either state law or contract to another organization that has undergone an audit by a nationally
recognized independent organization, that health plan company may use the nationally recognized
accrediting body's determination on its own behalf under this section.
    Subd. 4. Disclosure of national standards and reports. The health plan company shall:
(1) request that the nationally recognized independent organization provide to the
commissioner a copy of the current nationally recognized independent organization's standards
upon which the acceptable accreditation status has been granted; and
(2) provide the commissioner a copy of the most current final audit report issued by the
nationally recognized independent organization.
    Subd. 5. Accreditation not required. Nothing in this section requires a health plan company
to seek an acceptable accreditation status from a nationally recognized independent organization.
    Subd. 6. Continued authority. Nothing in this section precludes the commissioner from
conducting audits and investigations or requesting data as granted under the commissioner's
respective state authorizing statutes.
    Subd. 7. Human services. (a) The commissioner of human services shall implement this
section in a manner that is consistent with applicable federal laws and regulations and that
avoids the duplication of review activities performed by a nationally recognized independent
organization.
(b) By December 31 of each year, the commissioner shall submit to the legislature a written
report identifying the number of audits performed by a nationally recognized independent
organization that were accepted, partially accepted, or rejected by the commissioner under this
section. The commissioner shall provide the rationale for partial acceptance or rejection. If the
rationale for the partial acceptance or rejection was based on the commissioner's determination
that the standards used in the audit were not equivalent to state law, regulation, or contract
requirement, the report must document the variances between the audit standards and the
applicable state requirements.
    Subd. 8. Confidentiality. Any documents provided to the commissioner related to the audit
report that may be accepted under this section are private data on individuals pursuant to chapter
13 and may only be released as permitted under section 60A.03, subdivision 9.
History: 2004 c 288 art 6 s 8; 1Sp2005 c 4 art 8 s 4