This bill aims to modify the standards for utilization review performance in Minnesota by establishing a cause of action for wrongful denials of prior authorizations by utilization review organizations or their reviewing physicians. It amends Minnesota Statutes 2024, section 62M.04, subdivision 4, to require that prior to issuing an adverse determination, the reviewing physician must contact the attending health care professional to gather more information on the medical necessity of the service. Additionally, it introduces a new section, [62M.112], which outlines the conditions under which an enrollee can bring a cause of action against a utilization review organization for denial of prior authorization, including the requirement that the adverse determination deviates from accepted medical norms and causes injury to the enrollee.

Furthermore, the bill allows enrollees to file complaints with the commissioner regulating the utilization review organization and provides for attorney general enforcement of these provisions. It specifies that the attorney general may investigate and take action against a utilization review organization for violations. Importantly, the bill also clarifies that it does not create a cause of action against the attending health care professional of an enrollee whose prior authorization was denied, ensuring their immunity from civil liability in these cases.

Statutes affected:
Introduction: 62M.04