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62D.11 Complaint system.

Subdivision 1. Enrollee complaint system. Every health maintenance organization shall establish and maintain a complaint system, as required under section 62Q.105 to provide reasonable procedures for the resolution of written complaints initiated by or on behalf of enrollees concerning the provision of health care services. "Provision of health services" includes, but is not limited to, questions of the scope of coverage, quality of care, and administrative operations. The health maintenance organization must inform enrollees that they may choose to use alternative dispute resolution to appeal a health maintenance organization's internal appeal decision. If an enrollee chooses to use an alternative dispute resolution process, the health maintenance organization must participate.

Subd. 1a. Where a complaint involves a dispute about a health maintenance organization's coverage of a service, the commissioner may review the complaint and any information and testimony necessary in order to make a determination and order the appropriate remedy pursuant to sections 62D.15 to 62D.17.

Subd. 1b. Expedited resolution of complaints about medically urgent services. In addition to any remedy contained in subdivision 1a, when a complaint involves a dispute about a health maintenance organization's coverage of a medically urgent service, the commissioner may also order the health maintenance organization to use an expedited system to process the complaint.

Subd. 2. The health maintenance organization shall maintain a record of each written complaint filed with it for five years and the commissioner of health shall have access to the records.

Subd. 3. Denial of coverage. Within a reasonable time after receiving an enrollee's written or oral communication to the health maintenance organization concerning a denial of coverage or inadequacy of services, the health maintenance organization shall provide the enrollee with a written statement of the reason for the denial of coverage, and a statement approved by the commissioner of health which explains the health maintenance organization complaint procedures, and in the case of Medicare enrollees, which also explains Medicare appeal procedures.

Subd. 4. Repealed, 1997 c 205 s 40

HIST: 1973 c 670 s 11; 1974 c 284 s 5; 1977 c 305 s 45; 1986 c 444; 1988 c 434 s 10; 1988 c 592 s 6,7; 1990 c 538 s 22-24; 1995 c 234 art 2 s 1; 1997 c 205 s 12-14

Official Publication of the State of Minnesota
Revisor of Statutes