2005 Minnesota Statutes

     62Q.73 External review of adverse determinations. 

    Subdivision 1.    Definition.  For purposes of this 
 section, "adverse determination" means:  

    (1) a complaint decision relating to a health care service 
 or claim that has been appealed in accordance with section 
 62Q.70 and the appeal decision is partially or wholly adverse to 
 the complainant; 

    (2) any initial determination not to certify that has been 
 appealed in accordance with section 62M.06 and the appeal did 
 not reverse the initial determination not to certify; or 

    (3) a decision relating to a health care service made by a 
 health plan company licensed under chapter 60A that denies the 
 service on the basis that the service was not medically 
 necessary. 

 An adverse determination does not include complaints relating to 
 fraudulent marketing practices or agent misrepresentation. 

    Subd. 2.    Exception.  (a) This section does not apply 
 to governmental programs except as permitted under paragraph (b).
 For purposes of this subdivision, "governmental programs" means 
 the prepaid medical assistance program, the MinnesotaCare 
 program, the prepaid general assistance medical care program, 
 the demonstration project for people with disabilities, and the 
 federal Medicare program. 

    (b) In the course of a recipient's appeal of a medical 
 determination to the commissioner of human services under 
 section 256.045, the recipient may request an expert medical 
 opinion be arranged by the external review entity under contract 
 to provide independent external reviews under this section.  If 
 such a request is made, the cost of the review shall be paid by 
 the commissioner of human services.  Any medical opinion 
 obtained under this paragraph shall only be used by a state 
 human services referee as evidence in the recipient's appeal to 
 the commissioner of human services under section 256.045.  

    (c) Nothing in this subdivision shall be construed to limit 
 or restrict the appeal rights provided in section 256.045 for 
 governmental program recipients. 

    Subd. 3.    Right to external review.  (a) Any enrollee 
 or anyone acting on behalf of an enrollee who has received an 
 adverse determination may submit a written request for an 
 external review of the adverse determination, if applicable 
 under section 62Q.68, subdivision 1, or 62M.06, to the 
 commissioner of health if the request involves a health plan 
 company regulated by that commissioner or to the commissioner of 
 commerce if the request involves a health plan company regulated 
 by that commissioner.  Notification of the enrollee's right to 
 external review must accompany the denial issued by the insurer. 
 The written request must be accompanied by a filing fee of $25.  
 The fee may be waived by the commissioner of health or commerce 
 in cases of financial hardship. 

    (b) Nothing in this section requires the commissioner of 
 health or commerce to independently investigate an adverse 
 determination referred for independent external review. 

    (c) If an enrollee requests an external review, the health 
 plan company must participate in the external review.  The cost 
 of the external review in excess of the filing fee described in 
 paragraph (a) shall be borne by the health plan company.  

    Subd. 4.    Contract.  Pursuant to a request for 
 proposal, the commissioner of administration, in consultation 
 with the commissioners of health and commerce, shall contract 
 with an organization or business entity to provide independent 
 external reviews of all adverse determinations submitted for 
 external review.  The contract shall ensure that the fees for 
 services rendered in connection with the reviews be reasonable. 

    Subd. 5.    Criteria.  (a) The request for proposal must 
 require that the entity demonstrate: 

    (1) no conflicts of interest in that it is not owned, a 
 subsidiary of, or affiliated with a health plan company or 
 utilization review organization; 

    (2) an expertise in dispute resolution; 

    (3) an expertise in health-related law; 

    (4) an ability to conduct reviews using a variety of 
 alternative dispute resolution procedures depending upon the 
 nature of the dispute; 

    (5) an ability to provide data to the commissioners of 
 health and commerce on reviews conducted; and 

    (6) an ability to ensure confidentiality of medical records 
 and other enrollee information. 

    (b) The commissioner of administration shall take into 
 consideration, in awarding the contract according to subdivision 
 4, any national accreditation standards that pertain to an 
 external review entity. 

    Subd. 6.    Process.  (a) Upon receiving a request for 
 an external review, the external review entity must provide 
 immediate notice of the review to the enrollee and to the health 
 plan company.  Within ten business days of receiving notice of 
 the review, the health plan company and the enrollee must 
 provide the external review entity with any information that 
 they wish to be considered.  Each party shall be provided an 
 opportunity to present its version of the facts and arguments.  
 An enrollee may be assisted or represented by a person of the 
 enrollee's choice. 

    (b) As part of the external review process, any aspect of 
 an external review involving a medical determination must be 
 performed by a health care professional with expertise in the 
 medical issue being reviewed. 

    (c) An external review shall be made as soon as practical 
 but in no case later than 40 days after receiving the request 
 for an external review and must promptly send written notice of 
 the decision and the reasons for it to the enrollee, the health 
 plan company, and the commissioner who is responsible for 
 regulating the health plan company. 

    Subd. 7.    Standards of review.  (a) For an external 
 review of any issue in an adverse determination that does not 
 require a medical necessity determination, the external review 
 must be based on whether the adverse determination was in 
 compliance with the enrollee's health benefit plan. 

    (b) For an external review of any issue in an adverse 
 determination by a health plan company licensed under chapter 
 62D that requires a medical necessity determination, the 
 external review must determine whether the adverse determination 
 was consistent with the definition of medically necessary care 
 in Minnesota Rules, part 4685.0100, subpart 9b. 

    (c) For an external review of any issue in an adverse 
 determination by a health plan company, other than a health plan 
 company licensed under chapter 62D, that requires a medical 
 necessity determination, the external review must determine 
 whether the adverse determination was consistent with the 
 definition of medically necessary care in section 62Q.53, 
 subdivision 2. 

    Subd. 8.    Effects of external review.  A decision 
 rendered under this section shall be nonbinding on the enrollee 
 and binding on the health plan company.  The health plan company 
 may seek judicial review of the decision on the grounds that the 
 decision was arbitrary and capricious or involved an abuse of 
 discretion. 

    Subd. 9.    Immunity from civil liability.  A person who 
 participates in an external review by investigating, reviewing 
 materials, providing technical expertise, or rendering a 
 decision shall not be civilly liable for any action that is 
 taken in good faith, that is within the scope of the person's 
 duties, and that does not constitute willful or reckless 
 misconduct. 

    Subd. 10.    Data reporting.  The commissioners shall 
 make available to the public, upon request, summary data on the 
 decisions rendered under this section, including the number of 
 reviews heard and decided and the final outcomes.  Any data 
 released to the public must not individually identify the 
 enrollee initiating the request for external review. 

    HIST: 1999 c 239 s 39; 2000 c 474 s 2; 2001 c 215 s 27