State Law

Minnesota Statutes-Chapter 62M. Utilization Review of Health Care

08/08/2023 Minnesota Section 62M.07

Prior authorization of services

Retroactive Denial

See the bold text below:

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 to enrollees and​ providers and for notifying the provider, enrollee, or enrollee’s designee of appeal procedures​ under clause (4);​

(3) compliance with section 62M.05, subdivisions 3a and 3b, regarding time frames for​ authorizing and making adverse determinations regarding prior​ authorization requests;​

(4) written procedures to appeal adverse determinations of prior​ authorization requests which specify the responsibilities of the enrollee and provider, and​ which meet the requirements of sections 62M.06 and 72A.285, regarding release of summary​ review findings; and​

(5) procedures to ensure confidentiality of patient-specific information, consistent with​ applicable law.​

Subd. 2.  Prior authorization of emergency services prohibited. No utilization​ review organization, health plan company, or claims administrator may conduct or require​ prior authorization of emergency confinement or an emergency service. The​ enrollee or the enrollee’s authorized representative may be required to notify the health plan​ company, claims administrator, or utilization review organization as soon as reasonably​ possible after the beginning of the emergency confinement or emergency service.​

Retroactive Denial

Subd. 3.  Retrospective revocation or limitation of prior authorization.  No utilization​ review organization, health plan company, or claims administrator may revoke, limit,​ condition, or restrict a prior authorization that has been authorized unless there is evidence​ that the prior authorization was authorized based on fraud or misinformation or a previously​ approved prior authorization conflicts with state or federal law. Application of a deductible,​  coinsurance, or other cost-sharing requirement does not constitute a limit, condition, or​  restriction under this subdivision.​

Subd. 4.  Submission of prior authorization requests.  If prior authorization for a​ health care service is required, the utilization review organization, health plan company, or​ claim administrator must allow providers to submit requests for prior authorization of the​ health care services without unreasonable delay by telephone, facsimile, or voice mail or​ through an electronic mechanism 24 hours a day, seven days a week. This subdivision does not apply to dental service covered under MinnesotaCare or medical​ assistance.​