Summary
Prohibits utilization review organizations from using automated processing alone to make adverse clinical determinations. Requires clinician review by an appropriate health professional; physician reviewers generally must hold an unrestricted Minnesota license and have the same or a similar specialty as a provider who typically treats the condition. Prescription-drug determinations may be reviewed by a competent licensed pharmacist or physician.
Healthcare Implications
Requires covered health plans and utilization review organizations to keep qualified clinicians in the loop for adverse coverage decisions. Automated systems may support review but cannot independently deny care; the requirement applies to health plans offered, sold, issued, or renewed on or after January 1, 2027.
Operational Implications
- A utilization review organization may not make an adverse determination using automated processing alone; an appropriate clinician must review the determination, with physician reviewers generally licensed in Minnesota and practicing in the same or a similar specialty, and prescription-drug reviews performed by a competent licensed pharmacist or physician.