62M.01 CITATION, JURISDICTION, AND SCOPE. Subdivision 1. Popular name. This chapter may be cited as the “Minnesota Utilization Review Act of 1992.” Subd. 2. Jurisdiction. This chapter applies to any insurance company licensed under chapter 60A to offer, sell, or issue a policy of accident and sickness insurance as defined in section 62A.01; a health […]
62M.02 DEFINITIONS. Subdivision 1. Terms. For the purposes of this chapter, the terms defined in this section have the meanings given them. Subd. 1a. Adverse determination. “Adverse determination” means a decision by a utilization review organization relating to an admission, extension of stay, or health care service that is partially or wholly adverse to the […]
62M.03 COMPLIANCE WITH STANDARDS. Subdivision 1. Licensed utilization review organization. Beginning January 1, 1993, any organization that meets the definition of utilization review organization in section 62M.02, subdivision 21, must be licensed under chapter 60A, 62C, 62D, 62N, 62T, or 64B, or registered under this chapter and must comply with this chapter and section 72A.201, […]
62M.04 STANDARDS FOR UTILIZATION REVIEW PERFORMANCE. Subdivision 1. Responsibility for obtaining authorization. A health benefit plan that includes utilization review requirements must specify the process for notifying the utilization review organization in a timely manner and obtaining authorization for health care services. Each health plan company must provide a clear and concise description of this […]
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 […]
62M.06 APPEALS OF ADVERSE DETERMINATIONS. Subdivision 1. Procedures for appeal. (a) A utilization review organization must have written procedures for appeals of adverse determinations. The right to appeal must be available to the enrollee and to the attending health care professional. (b) The enrollee shall be allowed to review the information relied upon in the […]
62M.07 PRIOR AUTHORIZATION OF SERVICES. Subdivision 1. Written standards. Utilization review organizations conducting prior authorization of services must have written standards that meet at a minimum the following requirements: (1) written procedures and criteria used to determine whether care is appropriate, reasonable, or medically necessary; (2) a system for providing prompt notification of its determinations […]
62M.072 USE OF EVIDENCE-BASED STANDARDS. If no independently developed evidence-based standards exist for a particular treatment, testing, or imaging procedure, then an insurer or utilization review organization shall not deny coverage of the treatment, testing, or imaging based solely on the grounds that the treatment, testing, or imaging does not meet an evidence-based standard. This […]
62M.08 CONFIDENTIALITY. Subdivision 1. Written procedures to ensure confidentiality. A utilization review organization must have written procedures for ensuring that patient-specific information obtained during the process of utilization review will be: (1) kept confidential in accordance with applicable federal and state laws; (2) used solely for the purposes of utilization review, quality assurance, discharge planning, […]
62M.09 STAFF AND PROGRAM QUALIFICATIONS. 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 […]
62M.10 ACCESSIBILITY AND ON-SITE REVIEW PROCEDURES. Subdivision 1. Toll-free number. A utilization review organization must provide access to its review staff by a toll-free or collect call telephone line during normal business hours. A utilization review organization must also have an established procedure to receive timely callbacks from providers and must establish written procedures for […]
62M.11 COMPLAINTS TO COMMERCE OR HEALTH. Notwithstanding the provisions of this chapter, an enrollee may file a complaint regarding an adverse determination directly to the commissioner responsible for regulating the utilization review organization. History: 1992 c 574 s 11; 2020 c 114 art 2 s 15
62M.12 PROHIBITION OF INAPPROPRIATE INCENTIVES. No individual who is performing utilization review may receive any financial incentive based on the number of adverse determinations made by such individual, provided that utilization review organizations may establish medically appropriate performance standards. This prohibition does not apply to financial incentives established between health plan companies and providers. History: […]
62M.13 SEVERABILITY. If any provisions of this chapter are held invalid, illegal, or unenforceable for any reason and in any respect, the holding does not affect the validity of the remainder of this chapter. History: 1992 c 574 s 13; 2020 c 114 art 2 s 20
62M.14 EFFECT OF COMPLIANCE. Evidence of a utilization review organization’s compliance or noncompliance with the provisions of this chapter shall not be determinative in an action alleging that services denied were medically necessary and covered under the terms of the enrollee’s health benefit plan. History: 1992 c 574 s 14; 2020 c 114 art 2 […]
62M.15 APPLICABILITY OF OTHER CHAPTER REQUIREMENTS. The requirements of this chapter regarding the conduct of utilization review are in addition to any specific requirements contained in chapter 62A, 62C, 62D, 62Q, 62T, or 72A. History: 1992 c 574 s 15; 1999 c 239 s 31
62M.16 RULEMAKING. If it is determined that rules are reasonable and necessary to accomplish the purpose of this chapter, the rules must be adopted through a joint rulemaking process by both the Department of Commerce and the Department of Health. History: 1992 c 574 s 16; 2020 c 114 art 2 s 20
62M.17 CONTINUITY OF CARE; PRIOR AUTHORIZATIONS. Subdivision 1. Compliance with prior authorization approved by previous utilization review organization; change in health plan company. If an enrollee obtains coverage from a new health plan company and the health plan company for the enrollee’s new health benefit plan uses a different utilization review organization from the enrollee’s […]
62M.18 ANNUAL POSTING ON WEBSITE; PRIOR AUTHORIZATIONS. (a) By April 1, 2022, and each April 1 thereafter, a health plan company must post on the health plan company’s public website the following data for the immediately preceding calendar year for each commercial product: (1) the number of prior authorization requests for which an authorization was […]
