2007 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.
    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