Frequently Asked Questions - What is External Review?
External review is the program under which Minnesotans have been able to appeal denials (also referred to as adverse determinations) by a health plan company to an outside reviewer. This has been available since 1999 under state law. The federal Affordable Care Act has made some changes in the external review program: states must contract with at least three outside entities rather than one; cases will be assigned to entities on a random basis; the entities must be accredited by a nationally recognized private accrediting organization; if the entity completely reverses the adverse determination, the filing fee must be refunded.
Q. What is an adverse determination?
A. This is a decision by a health plan company to deny a health care service or a claim for services already provided.
Q. When is an external review available?
A. For someone enrolled in an individual health plan, external review is available when a complaint decision by the health plan company is unfavorable to the enrollee. However, an individual enrolled in a grandfathered individual health plan must first appeal a complaint decision before requesting external review.
For someone enrolled in a group health plan, external review is available when an appeal to the health plan company of a complaint is unfavorable to the enrollee.
Q. How does a consumer request an external review?
A. To initiate the external review process, you, the
enrollee, or anyone acting on behalf of the enrollee must complete an
external review form. You may request external review within six months of the date of the adverse determination. If you are enrolled in a Minnesota HMO, you may request the external review form by
phone, e-mail or by submitting a written request to:
Minnesota Department of Health
Managed Care Systems Section
P.O. Box 64882
St. Paul, MN 55164-0882
651-201-5100 or 1-800-657-3916
If you are enrolled in an insurance company or a Blue Cross and Blue Shield plan, you should contact the Minnesota Department of Commerce at 1-800-657-3602 or 651-539-1600 or fill out the application at Department of Commerce.
Q. What if my case is urgent and needs to be reviewed quickly?
A. To make a request for an expedited external review, the enrollee or representative may make the request by phone to the Department of Health. If the time to use mail would unreasonably delay the expedited external review, alternative means of information exchange (such as fax or e-mail) may be used. See below for details about the expedited review process.
Q. What if I am disabled, non-English speaking, or require assistance?
A. You (the enrollee), your representative or the HMO should contact the Department of Health (see contact information above) if the enrollee is disabled, non-English speaking, or requires assistance to submit an external review request.
Q. What is the fee for each external review?
A. There is a $25 fee for each external review. This fee will be refunded if the external review decision is in favor of the enrollee.
Q. Can I get a waiver of the $25 fee if it would be a financial hardship?
A. The $25 fee may be waived in cases of financial hardship. You should explain why payment of this fee would be a financial hardship and provide enough information to support your claim. Financial hardship may be based on any number of factors. For example, you might ask for a fee waiver based on family size and income, unusual or unexpected unpaid expenses, a recent change in family circumstances or a change in employment status. It is not enough to simply say that the fee would be a hardship, without providing an explanation for this statement.
Q. When can I expect an answer after requesting an external review?
A. A normal external review may take up to 45 days after the case is submitted to the independent review organization.
Q. What if I can't wait the normal 45 days for external review?
A. The State of Minnesota requires that the independent review organization be able to provide expedited reviews (in 72 hours or less). The terms are similar to health plan requirements for internal expedited appeals under Minnesota Statutes 62M.06. The consumer may submit and the independent review organization must accept, as an expedited review, any review in which an attending provider requests or feels such a review is appropriate.
Q. Why does the Department of Health review the external review request?
A. The Department of Health will screen each request for external review. The state review will cover three elements:
- Is the requestor enrolled in a fully insured plan
issued by a Minnesota HMO?
- Does the dispute involve a matter where the law requires
coverage and there is no factual dispute under the law? If so, the
Department of Health may exercise its regulatory authority to require
payment or service from the health plan without going to external
- For individual HMO health plans, have you received an adverse decision on a complaint? For group HMO health plans, have you received an adverse decision on an appeal of a complaint decision?
If the matter is ineligible due to the Department of Health's clear regulatory authority and no factual disputes, the Department of Health will proceed with any necessary investigation and enforcement with priority attention. You will be notified of the potential enforcement action and will be told that your fee may be either returned or held while enforcement action continues. If enforcement does not prove possible, the matter will be submitted to the independent review organization for external review.
If the requestor is not enrolled in a fully insured plan issued by a state licensed health plan company or has not exhausted the internal complaint and/or appeal process, the request will be ruled ineligible and the fee will be returned.
Q. How do I know if my case is appropriate for External Review?
A. If the request for external review is not accepted, the Department of Health or the independent review organization will contact you (the enrollee) and the HMO within two business days of receipt of your request application.
Q. Should I submit a complaint to the State of Minnesota or request an external review?
A. In making this decision, you may want to consider the following factors:
- How long can you wait for a decision on your complaint?
For those in individual health plans, you must first go through your plan's internal complaint process. This may take up to 30 days and another 14 days if the carrier cannot make a decision due to circumstances beyond its control. For those enrolled in group health plans, you must first go through your plan's internal complaint and appeal process. The appeal process may take up to 30 days for a written appeal and up to 45 days if the appeal used the hearing process. Expedited appeal is available for appeals based on medical necessity denials; these determinations must be made within 72 hours. Please note that your external review request must be filed within six months of the decision you are appealing.
Complaints filed with the Department of Health are not subject to a time limit. The time required for investigation and resolution varies. The Department of Health has the authority to investigate complaints filed by HMO enrollees. If the Department of Health determines that the HMO is in violation of law, it can order compliance and take enforcement action against the HMO for its violation, including administrative penalties. There is no filing fee for complaints filed with the State of Minnesota.
Does your complaint involve issues of complex, unproven,
experimental or investigative medical treatment or otherwise require
expert medical advice?
The independent review organization has readily available medical experts who will make a decision within 45 days. Expedited decisions are also available, allowing for a decision within 3 days. The decision must be based on all documents submitted by the HMO and the enrollee, including medical records, attending health provider's professional recommendation, consulting reports from health care professionals, terms of coverage, federal FDA approval, and medical or scientific evidence or evidence-based standards. The decision in each case is binding on the HMO but not on you (the enrollee) or on other similarly affected enrollees.
The Department of Health has the ability to contract with expert medical consultants when needed as part of a complaint investigation. It is unlikely that an investigation of complex, unproven, experimental or investigative medical treatment would be completed within 45 days.
- Does the issue in your complaint affect other enrollees as well as
Decisions reached by the independent review organization affect only the enrollee who filed the external review request. The State of Minnesota's decision can be enforced for all similarly affected enrollees. An HMO can appeal the State of Minnesota's decision through an administrative hearing and ultimately to state court.
- I don't know anything about the law. How do I know that my
complaint is a legal issue or that it is handled correctly?
The Minnesota Department of Health has experience investigating complaints filed by HMO enrollees. The staff understand state laws that govern Minnesota health plan companies.
Q. What if my case is already in litigation?
A. You may submit a complaint to the Department of Health only if your case is not already in litigation or has not been accepted for external review.
Q. Where can I call to get counseling on the process of external review or to check on the status of my external review as it applies to me?
A. The current independent review organization is:
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534-1302
Telephone: 1-866-763-6395 option 3