1998 Minnesota Statutes

     62Q.105 Health plan company complaint procedure. 

    Subdivision 1.    Establishment.  Each health plan 
 company shall establish and make available to enrollees, by July 
 1, 1999, an informal complaint resolution process that meets the 
 requirements of this section.  A health plan company must make 
 reasonable efforts to resolve enrollee complaints, and must 
 inform complainants in writing of the company's decision within 
 30 days of receiving the complaint.  The complaint resolution 
 process must treat the complaint and information related to it 
 as required under sections 72A.49 to 72A.505.  

    Subd. 2.    Medically urgent complaints.  Health plan 
 companies shall make reasonable efforts to resolve medically 
 urgent enrollee complaints within 72 hours of receiving the 
 complaint. 

    Subd. 3.    Appeals process.  Health plan companies 
 shall establish and make available to enrollees an impartial 
 appeals process.  If a decision by a health plan company 
 regarding a complaint is partially or wholly adverse to the 
 complainant, the health plan company shall advise the 
 complainant of the right to appeal through the impartial appeals 
 process or to the commissioner.  

    Subd. 4.    Alternative dispute resolution.  Health plan 
 companies shall make available to enrollees an alternative 
 dispute resolution process, and shall participate in alternative 
 dispute resolution at the request of an enrollee, as required 
 under section 62Q.11.  A health plan company may meet the 
 requirements of subdivision 3 by providing an alternative 
 dispute resolution process.  If the health plan company chooses 
 to provide alternative dispute resolution to meet the 
 requirements of subdivision 3, the process shall be provided at 
 no cost to the enrollee. 

    Subd. 5.    Requirements for managed care organizations. 
  Each managed care organization shall submit all health care 
 quality related complaints to its quality review board or 
 quality review organization for evaluation and possible action.  
 The complaint resolution process for managed care organizations 
 must clearly indicate the entity responsible for resolving 
 complaints made by enrollees against hospitals, other health 
 care facilities, and health care providers, that are owned by or 
 under contract with the managed care organization. 

    Subd. 6.    Recordkeeping.  Health plan companies shall 
 maintain records of all enrollee complaints and their 
 resolutions.  These records must be retained for five years, and 
 must be made available to the appropriate commissioner upon 
 request. 

    Subd. 7.    Reporting.  Each health plan company shall 
 submit to the appropriate commissioner, as part of the company's 
 annual filing, data on the number and type of complaints that 
 are not resolved within 30 days.  A health plan company shall 
 also make this information available to the public upon request. 

    Subd. 8.    Notice to enrollees.  Health plan companies 
 shall provide a clear and complete description of their 
 complaint resolution procedures to enrollees as part of their 
 evidence of coverage or contract.  The description must 
 specifically inform enrollees: 

    (1) how to file a complaint with the health plan company; 

    (2) how to request an impartial appeal; 

    (3) that they have the right to request the use of 
 alternative methods of dispute resolution; and 

    (4) that they have the right to litigate. 

    HIST: 1995 c 234 art 2 s 21; 1997 c 237 s 9; 1998 c 407 art 2 
 s 20