1997 Minnesota Statutes

     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 an admission, procedure, service, 
 or extension of stay.  The right to appeal must be available to 
 the enrollee or designee and to the attending physician.  The 
 right of appeal must be communicated to the enrollee or designee 
 or to the attending physician, whomever initiated the original 
 certification request, at the time that the original 
 determination is communicated. 

    Subd. 2.    Expedited appeal.  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 physician believes that the determination warrants 
 immediate appeal, the utilization review organization must 
 ensure that the attending physician, enrollee, or designee has 
 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.  Expedited appeals that are not resolved may be 
 resubmitted through the standard appeal process. 

    Subd. 3.    Standard appeal.  The utilization review 
 organization must establish procedures for appeals to be made 
 either in writing or by telephone. 

    (a) Each utilization review organization shall notify in 
 writing the enrollee or patient, attending physician, and claims 
 administrator of its determination on the appeal as soon as 
 practical, but in no case later than 45 days after receiving the 
 required documentation on the appeal. 

    (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 health care provider. 

    (c) Prior to upholding the original decision 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 original 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 patient, enrollee, or attending physician 
 when the initial determination is made. 

    (e) An attending physician 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, upon request of the attending physician, 
 ensure that a physician of the utilization review organization's 
 choice in the same or a similar general specialty as typically 
 manages the medical condition, procedure, or treatment under 
 discussion is reasonably available to review the case. 

    Subd. 4.    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.  

    HIST: 1992 c 574 s 6; 1994 c 625 art 2 s 13