72A.327 HEALTH CLAIMS; RIGHTS OF APPEAL.
(a) An insured whose claim for medical benefits under chapter 65B is denied because the
treatment or services for which the claim is made is claimed to be experimental, investigative, not
medically necessary, or otherwise not generally accepted by licensed health care providers and for
which the insured has financial responsibility in excess of applicable co-payments and deductibles
may appeal the denial to the commissioner.
(b) This section does not apply to claims for health benefits which have been arbitrated
65B.525, subdivision 1
(c) A three-member panel shall review the denial of the claim and report to the commissioner.
The commissioner shall establish a list of qualified individuals who are eligible to serve on
the panel. In establishing the list, the commissioner shall consult with representatives of the
contributing members as defined in section
65B.01, subdivision 2
, and professional societies.
Each panel must include: one person with medical expertise as identified by the contributing
members; one person with medical expertise as identified by the professional societies; and one
public member. The commissioner, upon initiation of an arbitration, shall select from each list
three potential arbitrators and shall notify the issuer and the claimant of the selection. Each party
shall strike one of the potential arbitrators and an arbitrator shall be selected by the commissioner
from the remaining names of potential arbitrators if more than one potential arbitrator is left.
In the event of multiparty arbitration, the commissioner may increase the number of potential
arbitrators and divide the strikes so as to afford an equal number of strikes to each adverse interest.
If the selected arbitrator is unable or unwilling to serve for any reason, the commissioner may
appoint an arbitrator, which will be subject to challenge only for cause. The party that denied the
coverage has the burden of proving that the services or treatment are experimental, investigative,
not medically necessary, or not generally accepted by licensed health care professionals. In
determining whether the burden has been met, the panel may consider expert testimony, medical
literature, and any other relevant sources. If the party fails to sustain its burden, the commissioner
may order the immediate payment of the claim. All proceedings of the panel and any documents
received or developed by the review process are nonpublic.
(d) A person aggrieved by an order under this section may appeal the order. The appeal shall
be pursuant to section
where appropriate, or to the district court for a trial de novo, in all
other cases. In nonemergency situations, if the insurer has an internal grievance or appeal process,
the insured must exhaust that process before the external appeal. In no event shall the internal
grievance process exceed the time limits described in section
72A.201, subdivision 4a
(e) If prior authorization is required before services or treatment can be rendered, an appeal
of the denial of prior authorization may be made as provided in this section.
(f) The commissioner shall adopt procedural rules for the conduct of appeals.
(g) The permanent rulemaking authority granted in this section is effective June 2, 1989,
regardless of the actual effective date of January 1, 1990.
History: 1989 c 330 s 34