Minnesota Administrative Rules
Agency 196 - Human Services Department
Chapter 9505 - HEALTH CARE PROGRAMS
CONDITIONS FOR MEDICAL ASSISTANCE AND GENERAL ASSISTANCE MEDICAL CARE PAYMENT
Part 9505.5076 - MEDICAL REVIEW AGENT DETERMINATION

Subpart 1. Qualified staff.

The medical review agent shall provide professional and technical expertise to conduct the second medical opinion program for medical assistance, general assistance medical care, and the MinnesotaCare programs. Unless otherwise specified in parts 9505.5035 to 9505.5105, the professional and technical expertise shall consist of persons who are physicians or who are registered nurses licensed under Minnesota Statutes, sections 148.171 to 148.285, to practice professional nursing and qualified by training and experience to review the appropriateness of surgical procedures.

Subp. 2. Medical review agent's determination upon receipt of required information.

The medical review agent must obtain and review the information required from the physician under part 9505.5075. If the medical review agent determines that the requested surgical procedure is medically appropriate, the medical review agent shall certify that the requirements of parts 9505.5035 to 9505.5105 are met and shall issue an authorization number. If the medical review agent determines that the requested surgical procedure is not medically appropriate, the medical review agent shall deny an authorization number. In either event, within 24 hours of receipt of the required information, exclusive of weekends and holidays, the medical review agent shall provide the notices required under part 9505.5082.

Subp. 3. Medical review agent unable to determine medical appropriateness.

If the medical review agent is unable to determine if a surgical procedure requiring a second opinion is medically appropriate, the medical review agent shall consult a physician adviser as specified in part 9505.5077.

Subp. 4. Retrospective review of medical record.

The medical review agent may conduct an on-site retrospective review of a recipient's inpatient hospital records on a surgical procedure to obtain information needed to make or verify a determination of medical appropriateness. If, after the review of the medical records, the medical review agent determines that the surgical procedure was not medically appropriate, the medical review agent shall deny an authorization number or, if an authorization number was issued, withdraw the authorization number. Upon completing the review, the medical review agent shall notify the physician as specified in part 9505.5082.