Need to Know–Top 12 Minnesota Regulations for Healthcare Prior Authorization

While recognizing the associated administrative hassles and clinical burdens, here are the top 13 areas that the American Medical Association (AMA) uses to monitor the various State Regulatory requirements placed on Prior Authorization.  Each state is unique in how they regulate the Insurance Industry.

Prior authorization is a health plan cost control process by which physicians and other health care providers must qualify for payment coverage by obtaining advance approval from a health plan before a specific service is delivered to the patient.

The AMA and others believe prior authorization is overused and existing processes present significant administrative and clinical concerns. These 12 areas should be reviewed when developing policies and procedures to manage Prior Authorizations.

1. State Law Regulating Prior Authorization
   • MN M.S.A. § 62M.05; M.S.A. § 62M.06 M.S.A. § 62M.07 SF 3204 2019
2. ePA and question set
   • NCPDP standard is mandated for prescribers and plans. If PA requirements for health care service, must allow providers to submit requests by telephone, fax, or voice mail or through an electronic mechanism 24 hours/day, 7 days/week Standard form: Sec. 4. MN Statutes 2018, section 62M.04, subdivision 3 limited
3. Response Times
   • Nonurgent: 5 business days after all info reasonably necessary to make a decision is provided and must provide “audit trail” of notification. Expedited determination is required if a provider says warranted. No later than 48 hrs and must include at least 1 business day after the initial request. When an expedited adverse determination is made, must also notify the patient and provider of right to submit an expedited appeal.
   • Plan must notify in writing the patient, provider, and claims administrator of the determination on the appeal w/in 15 days after receipt of the notice of appeal. If plan entity can’t make a determination w/in 15 days due to circumstances out of its control, may take up to 4 additional days. Anymore and must inform parties of the reason. Reviewer cannot be a physician who made adverse determinations.
4. PA length
   • When a patient changes plans, PA good for 60 days – provider/ patient must submit documentation of the previous PA to the new plan.
5. Retrospective denials
   • May not revoke, limit, condition, or restrict a PA unless there is evidence that the PA was authorized based on fraud or misinformation or a previously approved PA conflicts w/ state or federal law.
6. Data reporting
   • Every April, plans must post:

• 
  
  • # of PA requests for which an authorization was issued;
  • # of PA requests that adverse determination was issued and sorted by:
  • service; (ii) whether appealed;  (iii) whether upheld or reversed on appeal;
  • # of PA requests submitted electronically
  • reasons for denials including but not limited to:
  • patient did not meet PA criteria; (ii) incomplete info submitted; (iii) change in a treatment program; (iv) patient no longer covered.

7. Clinical criteria and medical necessity

• 
  
  • No Reference

     8. Notice of new requirements

• 
  
  • Electronic notice of new/amended requirements must be sent 45 days in advance to all MN-based, in-network attending providers who are subject to requirements. If, during the plan year, coverage terms change or the clinical criteria used to conduct PA change, do not apply until the next plan year for patients who received PA using former coverage terms or clinical criteria. Does not apply if deemed unsafe, if an independent source of research/ clinical guidelines or evidenced-based standards changes for reasons related to patient harm; or if replaced w/ generic rated as equivalent or biologic rates as interchangeable and 60-day notice given.

     9. Transparency

• 
  
  • Upon request, plans must provide criteria used to determine the necessity, appropriateness, and efficacy of service and identify the database, professional treatment parameter or another basis for the criteria. The plan must post on its public website PA requirements of the organization that performs UR review for the plan. The plan must have written standards:
    1. procedures and criteria used to determine if care is appropriate, reasonable, or medically necessary;
    2. a system for providing prompt notification of determinations and appeal procedures;
    3. compliance w/ time frames;
    4. procedures to appeal adverse determinations;
    5. procedures to ensure confidentiality of patient info.

       10. Qualifications of the reviewer

• 
  
  • In appeals to reverse an adverse determination for clinical reasons, the plan must ensure that a physician of the plan’s choice the same or a similar specialty as typically manages the medical condition, procedure, or treatment is reasonably available to review the case. No individual who is performing a utilization review may receive any financial incentive based on the number of adverse determinations made provided that utilization review organizations may establish medically appropriate performance standards.

        11. Exceptions/ gold carding

• 
  
  • No Reference

        12. Peer-to peer/appeal process/ other

• • No Reference

This list is ever-changing and should be reviewed prior to implementing any new policy and procedure.  We recommend the reaffirmation of existing policy regarding coverage for medically necessary treatment and the creation of a new policy supporting increased review of appeal determinations (beyond medical coding alone) by health plans and providers. There is work to reduce prior authorization requirements that could lead to the unintended and undesired consequence of increased post-payment reviews and therefore suggests reaffirmation of policy addressing concerns related to retrospective payment denials and review.

To learn more about Prior Authorization, please read out blog on  Need to Know – Top 12 Michigan Regulations for Healthcare Prior Authorization

Citation:  https://fixpriorauth.org/sites/default/files/2022 12/2022%20Prior%20Authorization%20State%20Law%20Chart.pdf