Minnesota Administrative Rules
Agency 196 - Human Services Department
Chapter 9505 - HEALTH CARE PROGRAMS
CONDITIONS FOR MEDICAL ASSISTANCE AND GENERAL ASSISTANCE MEDICAL CARE PAYMENT
Part 9505.5075 - PHYSICIAN RESPONSIBILITY
Current through Register Vol. 49, No. 13, September 23, 2024
When a surgical procedure is subject to a second medical opinion, the physician offering to provide the surgical procedure must contact the medical review agent for a determination of whether the surgical procedure is medically appropriate. The physician must request the determination of whether the surgical service is medically appropriate before submitting a claim for medical assistance payment. The claim for payment must have the authorization number given by the medical review agent and must comply with the requirements of part 9505.0450.
The physician must give the medical review agent the following information by telephone:
A. the recipient's name, ID number, and date of birth;
B. the admitting physician's name and provider number;
C. the primary procedure code according to the most recent edition of Physicians' Current Procedural Terminology published by the American Medical Association or the International Classification of Diseases -- Clinical Modification, published by the Commission on Professional and Hospital Activities, Green Road, Ann Arbor, Michigan 48105, which is incorporated by reference and available through the Minitex interlibrary loan system and is subject to change;
D. the expected date of the surgical procedure;
E. the recipient's diagnosis by diagnostic code according to the most recent edition of the International Classification of Diseases -- Clinical Modification;
F. information from the recipient's medical record sufficient to enable the medical review agent to determine if the surgical procedure meets the criteria in part 9505.5046;
G. whether the surgical procedure is in response to an emergency;
H. whether the surgical procedure is a consequence of, or a customary and accepted practice incident to, a more major surgical procedure; and
I. the name and provider number of the inpatient or outpatient hospital where the surgical procedure was or will be performed.
Statutory Authority: MS s 256.0625; 256.991; 256D.03
