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S.F. No. 3204 - Changes to Utilization Review and Prior Authorization (1st Engrossment)
 
Author: Senator Julie A. Rosen
 
Prepared By: Katie Cavanor, Senate Counsel (651/296-3801)
 
Date: May 6, 2020



 

S.F. 3204 modifies a number of utilization review and prior authorization requirements for utilization review organizations when conducting utilization reviews. S.F. 3204 also modifies the terminology used in chapter 62M and creates continuity within chapter 62M.

Article 1: Utilization review and Prior Authorization of Health Care Services

Section 1 (62M.01, subd. 2) Adds to the jurisdiction section clarification that chapter 62M applies to any entity that provides, offers, or administers hospital, outpatient, medical, prescription drug, or other health benefits to individuals treated by health professional under a health benefit plan.

Section 2 (62M.02, subd. 1a) adds a definition of adverse determination.

Section 3 (62M.02, subd. 5) changes the term “certification” to “authorization.”

Section 4 (62M.02, subd. 8) clarifies the definition of “clinical criteria” to include clinical protocols or any other criteria or rationale used by the URO to determine whether the health care service is authorized.

Section 5 (62M.02, subd. 10a) adds a definition of “emergency services.”

Section 6 (62M.02, subd. 13a) adds a definition of “medically necessary.”

Section 7 (62M.02, subd. 20) clarifies that the definition of “utilization review” includes prior authorization and review conducted after the admission of the enrollee.

Section 8 (62M.02, subd. 21) clarifies that the definition of “utilization review organization” (URO) includes any entity that provides, offers, or administers hospital, outpatient, medical, prescription drug, or other health benefits to individuals treated by a health professional under a health benefit plan. Also changes terminology from certification to authorizes or makes adverse determinations.

Section 9 (62M.05, subd. 3a) specifies that notification of an adverse determination must be provided within five business days after receiving the request to the attending health care professional and hospital or physician office. Specifies the written notification must include all reasons relied upon by the URO for the determination. Also changes terminology to the standard review determination.

Section 10 (62M.05, subd. 3b) requires that notification of an expedited adverse determination be provided to the hospital, attending health care professional, and enrollee no later than 48 hours and must include at least one business day after the initial request (currently, notification must be provided no later than 72 hours). Also changes terminology to the expediated review determination. 

Section 11 (62M.05, subd. 4) clarifies that a URO must have written procedures to address the failure of a provider or enrollee to provide the information necessary to make a determination on the request. Also changes terminology.

Section 12 (62M.06, subd. 3) requires that notification of the URO’s determination of an appeal must be provided in writing to the enrollee, health care professional, and claims administrator within 15 days after receipt of the notice of appeal. If the URO cannot make a determination within 15 days due to circumstances outside the control of the URO, the URO my take up to four additional days. If additional days beyond the initial 15 days are taken by the URO, the URO must notify the enrollee, attending health care professional, and claims administrator in advance of the extension and the reasons for it (currently, the time of notification is within 30 days with an additional 30 days). Also changes terminology.

Section 13 (62M.07) makes changes to the prior authorization (PA) of services.

Subdivisions 1 and 2 change terminology.

Subd. 3 specifies that no URO, health plan company, or claims administrator may revoke, limit, condition, or restrict a PA that has been authorized unless there is evidence that the prior PA was authorized based on fraud or misinformation or it conflicts with state or federal law. Cost sharing requirements does not constitute a limit.

Subd. 4 makes a technical change.

Section 14 (62M.09, subd. 3) specifies that a physician must review cases where the URO has concluded that an adverse determination for clinical is appropriate. Requires the physician reviewer to hold a current unrestricted license to practice medicine in the state and must have the same or similar medical specialty as a provider that typically treat or manages the condition for which the health care service has been requested. Also specifies that a review of an adverse determination involving a prescription drug must be conducted by either a licensed pharmacist who is competent to evaluate the clinical issues presented or a physician who holds a current, unrestricted license to practice medicine in the state and practices in the same or similar medical specialty that treats or manages the condition for which the drug is being requested.

Section 15 (62M.10, subd. 7) specifies that for PA determinations a URO must submit the URO’s current PA requirements and restrictions, including written, evidence-based clinical criteria used to make an authorization or adverse determination to all health plan companies for which the URO performs utilization review. Requires the health plan company to post on its public website the PA requirements and restrictions of any URO that performs utilization review for the health plan company.

Section 16 (62M.10, subd. 8) Paragraph (a) states that before a URO may implement a new PA requirement or restriction or amend existing PA requirments or restrictions, the URO must submit the new or amended requirement or restriction to all health plan companies for which the URO performs utilization reviews.  Requires the health plan company to post on it website the new or amended requirement or restriction.

Paragraph (b) requires a URO, health plan company (HPC), or claims administrator at least 45 days before the implementation of a new PA requirement or restriction or an amended existing PA requirement or restriction, to provide written or electronic notice of the new or amended requirement  or restriction to all Minnesota based, in network attending health care professionals who are subject to the PA requirements and restrictions.

Paragraph (c) specifies that this section does not apply to managed care plans or county-based purchasing plans when the plan is providing coverage for  public health care program enrollees under chapter 256B or 256L.

Section 17 (62M.17) establishes continuity of care for prior authorizations.

Subdivision 1 specifies that if an enrollee obtains coverage from a new health plan company and the new health plan company uses a different URO from the enrollee’s previous health plan company to conduct utilization review, the new health plan company must comply with a PA for health care services approved by the URO used by the enrollee’s previous health plan company for at least the first 60 days of coverage under the new health benefit plan.  Requires the attending health care professional or the enrollee to submit documentation of the previous PA to the enrollee’s new HPC. The enrollee’s new health plan company may conduct a new utilization review within the 60 day period.

Subd. 2 paragraph (a) specifies that if a URO, HPC, or claims administrator changes coverage terms for a health care service or the clinical criteria used to conduct PA of a health care service during a plan year, the URO, HPC, or claims administrator must not apply the change in coverage terms or in clinical criteria until the new plan year for any enrollee who received PA for a health care service using the coverage terms or clinical criteria in effect before the effective date of the change.

Paragraph (b) states that paragraph (a) does not apply if a URO, HPC, or claims administrator changes coverage terms for a drug or device that has been deemed unsafe by the FDA; has been withdrawn by either the FDA or the product manufacturer; or when an independent source of research, clinical guidelines, or evidence based standards has issued drug or device specific warning or has recommended changes in drug or device usage.

Paragraph (c) states that paragraph (a) does not apply changes coverage terms for a service or the clinical criteria used to conduct PAs for a service when an independent sour e of research, clinical guidelines, or evidence based standards has recommended changes in usage for reasons related to patient harm.

Paragraph (d) states that paragraph (a) does not apply if a URO, HPC, or claims administrator removes a brand name drug from its formulary or places a brand name drug in a benefit category that increases the enrollee’s cost provided that (1) a generic or multisource brand name drug rated as therapeutically equivalent according to the FDA orange book or a biologic drug rated as interchangeable according to the FDA purple book, at a lower cost to the enrollee is added to the formulary; and (2) at least a 60-day notice is provided to prescribers, pharmacists, and affected enrollees.

Subd. 3 specifies that this section does not apply to public health care programs administered under chapter 256B or 256L.

Section 18 (62M.18) requires a health plan company to annually post on its public website for each commercial product beginning April 1, 2022, the following:

  1. the number of PA requests for which authorization is issued;
  2. the number of PA requests for which an adverse determination was issued and whether the determination was appealed and the outcome of the appeal;
  3. the number of PA requests that were submitted electronically; and
  4. the reasons for PA denial.

Section 19 requires the commissioner of health to submit to the legislature a report on compliance with the provider requirements in Minnesota Statutes, section 62J.497, subd. 5 (electronic drug prior authorization standardization and transmission) from information collected by the commissioner from health plans offered in the commercial fully insured and self-insured health insurance markets.

Section 20 repeals Minnesota Statutes, section 62M.02, subd. 19 (definition of reconsideration request); and Minnesota Rules 4685.0110, subpart 9b.

Article 2: Conforming Changes

Article 2 makes terminology changes consistent to the changes in Article 1 in various statutes.

 
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