Subdivision 1. Establishment. Each health plan company must establish and maintain an internal complaint resolution process that meets the requirements of this section to provide for the resolution of a complaint initiated by a complainant.
Subd. 2. Procedures for filing a complaint. (a) A complainant may submit a complaint to a health plan company either by telephone or in writing. If a complaint is submitted orally and the resolution of the complaint, as determined by the complainant, is partially or wholly adverse to the complainant, or the oral complaint is not resolved to the satisfaction of the complainant, by the health plan company within ten days of receiving the complaint, the health plan company must inform the complainant that the complaint may be submitted in writing. The health plan company must also offer to provide the complainant with any assistance needed to submit a written complaint, including an offer to complete the complaint form for a complaint that was previously submitted orally and promptly mail the completed form to the complainant for the complainant's signature. At the complainant's request, the health plan company must provide the assistance requested by the complainant. The complaint form must include the following information:
(1) the telephone number of the health plan company member services or other departments or persons equipped to advise complainants on complaint resolution;
(2) the address to which the form must be sent;
(3) a description of the health plan company's internal complaint procedure and the applicable time limits; and
(4) the toll-free telephone number of either the commissioner of health or commerce and notification that the complainant has the right to submit the complaint at any time to the appropriate commissioner for investigation.
(b) Upon receipt of a written complaint, the health plan company must notify the complainant within ten business days that the complaint was received, unless the complaint is resolved to the satisfaction of the complainant within the ten business days.
(c) Each health plan company must provide, in the member handbook, subscriber contract, or certification of coverage, a clear and concise description of how to submit a complaint and a statement that, upon request, assistance in submitting a written complaint is available from the health plan company.
Subd. 3. Notification of complaint decisions. (a) The health plan company must notify the complainant in writing of its decision and the reasons for it as soon as practical but in no case later than 30 days after receipt of a written complaint. If the health plan company cannot make a decision within 30 days due to circumstances outside the control of the health plan company, the health plan company may take up to 14 additional days to notify the complainant of its decision. If the health plan company takes any additional days beyond the initial 30-day period to make its decision, it must inform the complainant, in advance, of the extension and the reasons for the extension.
(b) For group health plans, if the decision is partially or wholly adverse to the complainant, the notification must inform the complainant of the right to appeal the decision to the health plan company's internal appeal process described in section 62Q.70 and the procedure for initiating an appeal.
(c) For individual health plans, if the decision is partially or wholly adverse to the complainant, the notification must inform the complainant of the right to submit the complaint decision to the external review process described in section 62Q.73 and the procedure for initiating the external review process. Notwithstanding the provisions in this subdivision, a health plan company offering individual coverage may instead follow the process for group health plans outlined in paragraph (b).
(d) The notification must also inform the complainant of the right to submit the complaint at any time to either the commissioner of health or commerce for investigation and the toll-free telephone number of the appropriate commissioner.
1999 c 239 s 35; 2008 c 221 s 1; 2013 c 84 art 1 s 82
Structure Minnesota Statutes
Chapters 59A - 79A — Insurance
Chapter 62Q — Health Plan Companies
Section 62Q.02 — Applicability Of Chapter.
Section 62Q.021 — Federal Act; Compliance Required.
Section 62Q.025 — High Deductible Health Plans.
Section 62Q.03 — Process For Risk Adjustment System.
Section 62Q.075 — Local Public Accountability And Collaboration Plan.
Section 62Q.096 — Credentialing Of Providers.
Section 62Q.097 — Requirements For Timely Provider Credentialing.
Section 62Q.101 — Evaluation Of Provider Performance.
Section 62Q.1055 — Chemical Dependency.
Section 62Q.106 — Dispute Resolution By Commissioner.
Section 62Q.107 — Prohibited Provision; Judicial Review.
Section 62Q.12 — Denial Of Access.
Section 62Q.121 — Licensure Of Medical Directors.
Section 62Q.135 — Contracting For Chemical Dependency Services.
Section 62Q.137 — Chemical Dependency Treatment; Coverage.
Section 62Q.14 — Restrictions On Enrollee Services.
Section 62Q.145 — Abortion And Scope Of Practice.
Section 62Q.16 — Midmonth Termination Prohibited.
Section 62Q.165 — Universal Coverage.
Section 62Q.17 — Voluntary Purchasing Pools.
Section 62Q.18 — Portability Of Coverage.
Section 62Q.181 — Written Certification Of Coverage.
Section 62Q.184 — Step Therapy Override.
Section 62Q.1841 — Prohibition On Use Of Step Therapy For Metastatic Cancer.
Section 62Q.185 — Guaranteed Renewability; Large Employer Group.
Section 62Q.186 — Prohibition On Rescissions Of Health Plans.
Section 62Q.188 — Flexible Benefits Plans.
Section 62Q.19 — Essential Community Providers.
Section 62Q.22 — Health Care Services Prepaid Option.
Section 62Q.23 — General Services.
Section 62Q.32 — Local Ombudsperson.
Section 62Q.33 — Local Government Public Health Functions.
Section 62Q.37 — Audits Conducted By Independent Organization.
Section 62Q.43 — Geographic Access.
Section 62Q.45 — Coverage For Out-of-area Primary Care.
Section 62Q.46 — Preventive Items And Services.
Section 62Q.47 — Alcoholism, Mental Health, And Chemical Dependency Services.
Section 62Q.471 — Exclusion For Suicide Attempts Prohibited.
Section 62Q.472 — Screening And Testing For Opioids.
Section 62Q.48 — Cost-sharing In Prescription Insulin Drugs.
Section 62Q.49 — Enrollee Cost Sharing; Negotiated Provider Payments.
Section 62Q.50 — Prostate Cancer Screening.
Section 62Q.51 — Point-of-service Option.
Section 62Q.52 — Direct Access To Obstetric And Gynecologic Services.
Section 62Q.521 — Postnatal Care.
Section 62Q.525 — Coverage For Off-label Drug Use.
Section 62Q.526 — Coverage For Participation In Approved Clinical Trials.
Section 62Q.527 — Nonformulary Antipsychotic Drugs; Required Coverage.
Section 62Q.528 — Drug Coverage In Emergency Situations.
Section 62Q.529 — Coverage For Drugs Prescribed And Dispensed By Pharmacies.
Section 62Q.53 — Mental Health Coverage; Medically Necessary Care.
Section 62Q.535 — Coverage For Court-ordered Mental Health Services.
Section 62Q.54 — Referrals For Residents Of Health Care Facilities.
Section 62Q.545 — Coverage Of Home Care Nursing.
Section 62Q.55 — Emergency Services.
Section 62Q.556 — Unauthorized Provider Services.
Section 62Q.56 — Continuity Of Care.
Section 62Q.57 — Designation Of Primary Care Provider.
Section 62Q.58 — Access To Specialty Care.
Section 62Q.645 — Efficiency Reports And Distribution Of Information.
Section 62Q.65 — Access To Provider Discounts.
Section 62Q.66 — Durable Medical Equipment Coverage.
Section 62Q.67 — Disclosure Of Covered Durable Medical Equipment.
Section 62Q.675 — Hearing Aids; Persons 18 Or Younger.
Section 62Q.676 — Medication Therapy Management.
Section 62Q.677 — Lifetime And Annual Limits.
Section 62Q.678 — Dependent Child Notice.
Section 62Q.69 — Complaint Resolution.
Section 62Q.70 — Appeal Of The Complaint Decision.
Section 62Q.71 — Notice To Enrollees.
Section 62Q.72 — Record Keeping; Reporting.
Section 62Q.73 — External Review Of Adverse Determinations.
Section 62Q.731 — Appeal From Adverse Determination.
Section 62Q.733 — Definitions.
Section 62Q.735 — Provider Contracting Procedures.
Section 62Q.736 — Payment Rates.
Section 62Q.737 — Service Code Changes.
Section 62Q.739 — Unilateral Terms Prohibited.
Section 62Q.74 — Network Shadow Contracting.
Section 62Q.746 — Access To Certain Information Regarding Providers.
Section 62Q.75 — Prompt Payment Required.
Section 62Q.751 — Collecting Deductibles And Coinsurance.
Section 62Q.77 — Terms Of Coverage Disclosure.
Section 62Q.78 — Dental Benefit Plan Requirements.
Section 62Q.80 — Community-based Health Care Coverage Program.
Section 62Q.81 — Essential Health Benefit Package Requirements.