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Minnesota Legislature

Office of the Revisor of Statutes

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