Minnesota Administrative Rules

9500.1463 COMPLAINT AND APPEAL PROCEDURES.

Subpart 1.

[Repealed, 16 SR 1086]

Subp. 2.

[Repealed, 16 SR 1086]

Subp. 3.

Health plan complaint procedure.

A health plan shall have a written procedure for reviewing enrollee complaints. This complaint procedure must be approved by the commissioner. The complaint procedure must include both an informal process, in which a determination is made within ten calendar days after the date a health plan receives a verbal complaint, and a formal process to handle written complaints. The formal process shall provide for an impartial hearing containing the elements in items A to D.

A.

A person or persons with authority to resolve the case shall be designated to hear the complaint.

B.

The enrollee has the right to be represented at the hearing by a representative of his or her choice, including legal counsel.

C.

The enrollee and the health plan may call witnesses to provide relevant testimony.

D.

A determination shall be made and written notice of the decision shall be issued to the enrollee within 30 days after the date the written complaint is received by the health plan. The written notice shall include notice of the enrollee's right to appeal to the state.

Each health plan shall provide its enrollees with a written description of the health plan's complaint procedure and the state's appeal procedure at the time of enrollment. The written description shall clearly state that exhaustion of the health plan's complaint procedure is not required before appealing to the state. The health plan's complaint procedure and revisions to the complaint procedure must be approved by the commissioner. Approved revisions in the health plan's complaint procedure must be communicated, in writing, to its enrollees at least two weeks before the revisions are implemented.

Subp. 4.

Health plan notice requirements.

When a health plan denies, reduces, or terminates a health service, it must notify the enrollee or the enrollee's authorized representative in writing of the right to file a complaint or appeal according to Minnesota Statutes, section 256.045, subdivision 3. The notice must explain:

A.

the right to a second opinion within the plan;

B.

how to file a complaint;

C.

how to file a state appeal, including the name and telephone number of the state ombudsperson;

D.

the circumstances under which health services may be continued pending an appeal; and

E.

the right to request an expedited hearing under Minnesota Statutes, section 256.045, subdivision 3a, paragraph (c).

For purposes of this subpart, a health plan does not include the treating physician, second opinion physician, or other treating health care professional whether employed by, or contracting with, the health plan.

Subp. 5.

State appeal procedure.

An enrollee may appeal the refusal to change a health plan or primary care provider under part 9500.1453, subparts 7 and 8, a health plan's or participating provider's denial, delay, reduction, or termination of health services or a health plan's resolution of a complaint or any other ruling of a prepaid health plan by submitting a written request for a hearing as provided in Minnesota Statutes, section 256.045, subdivision 3. The enrollee may request an expedited hearing by contacting the appeals referee or ombudsperson. A state human services referee shall conduct a hearing on the matter and shall recommend an order to the commissioner. An enrollee is not required to exhaust the health plan's complaint system before filing a state appeal. An enrollee may request the assistance of the ombudsperson or other persons in the appeal process.

Subp. 6.

Services pending state appeal or resolution of complaint.

If an enrollee files a written complaint with the health plan or appeals in writing to the state under Minnesota Statutes, section 256.045, on or before the tenth day after the decision is communicated to the enrollee by the health plan to reduce, suspend, or terminate services the enrollee had been receiving on an ongoing basis, or before the date of the proposed action, whichever is later, and the treating plan physician or another plan physician has ordered the services at the present level and is authorized by the contract with the health plan to order the services, the health plan must continue to provide services at a level equal to the level ordered by the plan physician until written resolution of the complaint is made by the health plan or a decision on the appeal is made by the human services referee. If the resolution is adverse, in whole or part, to the enrollee, the enrollee must be notified of the right to a state appeal. If the enrollee appeals a health plan's written resolution within ten days after it is issued, or before the date of the proposed action, whichever is later, services must be continued pending a decision by the human services referee. A resolution is made or issued on the date it is mailed or the date postmarked, whichever is later. For the purposes of this subpart, "plan physician," where appropriate, includes a plan dentist, mental health professional, chiropractor, or osteopathic physician, nurse practitioner, or nurse midwife.

Subp. 7.

State ombudsperson.

The commissioner shall designate a state ombudsperson to help enrollees resolve health plan service related problems. Upon an enrollee's request, the ombudsperson shall investigate the enrollee's case and when appropriate attempt to resolve the problem in an informal manner by serving as an intermediary between the enrollee and the health plan. If the enrollee requests appeal information, or if the ombudsperson believes that an informal resolution is not feasible or is unable to obtain a resolution of the problem, the ombudsperson shall explain to the enrollee what his or her complaint and appeal options are, how to file a complaint or appeal, how the complaint or appeal process works and assist the enrollee in presenting the enrollee's case to the appeals referee, when requested. The ombudsperson must be available to help the enrollee file a written complaint or appeal request. The ombudsperson must notify the appropriate health plan of a state appeal within three working days after the state appeal is filed.

Subp. 8.

Record keeping and reporting requirements.

The health plan must maintain a record of all written complaints from enrollees, actions taken in response to those complaints, and the final disposition of the complaints. The health plan must report this information to the commissioner on a semiannual basis.

Statutory Authority:

MS s 256.045; 256B.031; 256B.69

History:

11 SR 1107; 16 SR 1086; 32 SR 565; L 2016 c 119 s 7

Published Electronically:

September 12, 2016