1998 Minnesota Statutes

     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 and section 72A.201, subdivision 4a. 

    Subd. 2.    Concurrent review.  A utilization review 
 organization may review ongoing inpatient stays based on the 
 severity or complexity of the patient'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 the following: 

    (a) 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 hospital, attending physician, or 
 applicable service provider within ten business days of the 
 determination in accordance with section 72A.201, subdivision 
 4a, 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 or patient; 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." 

    (b) When a determination is made not to certify a hospital 
 or surgical facility admission or extension of a hospital stay, 
 or other service requiring review determination, within one 
 working day after making the decision the attending physician 
 and hospital must be notified by telephone and a written 
 notification must be sent to the hospital, attending physician, 
 and enrollee or patient.  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 
 attending physician or provider 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 attending 
 physician. 

    Subd. 4.    Failure to provide necessary information.  A 
 utilization review organization must have written procedures to 
 address the failure of a health care provider, patient, or 
 representative of either to provide the necessary information 
 for review.  If the patient 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. 

    HIST: 1992 c 574 s 5; 1994 c 485 s 65; 1994 c 625 art 2 s 12