Subdivision 1. Quality of care complaint. For purposes of this section, "quality of care complaint" means an expressed dissatisfaction regarding health care services resulting in potential or actual harm to an enrollee. Quality of care complaints may include the following, to the extent that they affect the clinical quality of health care services rendered: access; provider and staff competence; clinical appropriateness of care; communications; behavior; facility and environmental considerations; and other factors that could impact the quality of health care services.
Subd. 2. Quality of care complaint investigation. (a) Each health maintenance organization shall develop and implement a quality of care complaint investigation process that meets the requirements of this section. The process must include a written policy and procedures for the receipt, investigation, and follow-up of quality of care complaints, that includes the requirements in paragraphs (b) to (h).
(b) A health maintenance organization's definition for quality of care complaints must include the concerns identified in subdivision 1.
(c) A health maintenance organization must include a description of each quality of care complaint level of severity, including:
(1) classification of complaints that warrant peer protection confidentiality as defined by the commissioner in paragraph (h); and
(2) investigation procedures for each level of severity.
(d) Any complaint with an allegation regarding quality of care or service must be investigated by the health maintenance organization. Documentation must show that each allegation has been addressed.
(e) Conclusions of each investigation must be supported with evidence that may include an associated corrective action plan implemented and documented and a formal response from a provider to the health maintenance organization if a formal response was submitted to the health maintenance organization. The record of investigation must include all related documents, correspondence, summaries, discussions, consultation, and conferences held.
(f) A medical director review shall be conducted as part of the investigation process when there is potential for patient harm.
(g) Each quality of care complaint received by a health maintenance organization must be tracked and trended for review by the health maintenance organization according to provider type and the following type of quality of care issue: behavior, facility, environmental, or technical competence.
(h) The commissioner, in consultation with interested stakeholders, shall define complaints that are subject to peer protection confidentiality in accordance with state and federal law by January 1, 2018.
Subd. 3. Complaint reporting. Each health maintenance organization shall submit to the commissioner, as part of the company's annual filing, data on the number of complaints and the category as defined by the commissioner as required under section 62D.08, subdivision 3, clause (f).
Subd. 4. Records. Each health maintenance organization shall maintain records of all quality of care complaints and their resolution and retain those records for five years. Notwithstanding section 145.64, information provided to the commissioner according to this subdivision is classified as confidential data on individuals or protected nonpublic data as defined in section 13.02, subdivision 3 or 13.
Subd. 5. Exception. This section does not apply to quality of care complaints received by a health maintenance organization from an enrollee who is covered under a public health care program administered by the commissioner of human services under chapter 256B or 256L.
2016 c 189 art 20 s 4
Structure Minnesota Statutes
Chapters 59A - 79A — Insurance
Chapter 62D — Health Maintenance Organizations
Section 62D.01 — Citation And Purpose.
Section 62D.03 — Establishment Of Health Maintenance Organizations.
Section 62D.04 — Issuance Of Certificate Authority.
Section 62D.041 — Protection In The Event Of Insolvency.
Section 62D.042 — Initial Net Worth Requirement.
Section 62D.044 — Admitted Assets.
Section 62D.045 — Investment Restrictions.
Section 62D.05 — Powers Of Health Maintenance Organizations.
Section 62D.06 — Governing Body.
Section 62D.07 — Evidence Of Coverage; Required Terms.
Section 62D.08 — Annual Report.
Section 62D.09 — Information To Enrollees.
Section 62D.095 — Enrollee Cost Sharing.
Section 62D.10 — Provisions Applicable To All Health Plans.
Section 62D.101 — Continuation And Conversion Privileges For Former Spouses And Children.
Section 62D.102 — Family Therapy.
Section 62D.103 — Second Opinion Related To Substance Use Disorder And Mental Health.
Section 62D.104 — Required Out-of-area Conversion.
Section 62D.105 — Coverage Of Current Spouse, Former Spouse, And Children.
Section 62D.107 — Equal Access To Acupuncture Services.
Section 62D.109 — Services Associated With Clinical Trials.
Section 62D.11 — Complaint System.
Section 62D.115 — Quality Of Care Complaints.
Section 62D.12 — Prohibited Practices.
Section 62D.121 — Required Replacement Coverage.
Section 62D.123 — Provider Contracts.
Section 62D.124 — Geographic Accessibility.
Section 62D.13 — Powers Of Insurers And Nonprofit Health Service Plans.
Section 62D.14 — Examinations.
Section 62D.145 — Disclosure Of Information Held By Health Maintenance Organizations.
Section 62D.15 — Suspension Or Revocation Of Certificate Of Authority.
Section 62D.16 — Denial, Suspension, And Revocation; Administrative Procedures.
Section 62D.17 — Penalties And Enforcement.
Section 62D.18 — Rehabilitation Or Liquidation Of Health Maintenance Organization.
Section 62D.181 — Insolvency; Mcha Alternative Coverage.
Section 62D.182 — Liabilities.
Section 62D.19 — Unreasonable Expenses.
Section 62D.211 — Renewal Fee.
Section 62D.22 — Statutory Construction And Relationship To Other Laws.
Section 62D.23 — Filings And Reports As Public Documents.
Section 62D.24 — Commissioner Of Health's Authority To Contract.