Frequently Asked Questions - How External Review Works For You
Minnesotans are entitled to an independent external review when they disagree with denials that their health plan has made concerning requested services or payment for services. The State of Minnesota contracts with Maximus, an independent company that independently reviews the appeals made by the individuals. Maximus, its employees and physician consultants are impartial and separate from the health plan, and has no affiliation with any health plan. To request an external review, enrollees must complete an external review form and send it to the Minnesota Department of Health.
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 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
Email: health.mcs@state.mn.us
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 health plan 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. A check payable to "Maximus - Minnesota Appeal" must be included with the completed form. If an external review is initiated, the fee is non-refundable.
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 usually takes 40 days after the case is submitted to the independent review organization.
Q. What if I can't wait the normal 40 days for external review?
A. The State of Minnesota requires that the independent review organization 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 state licensed health plan company?
- 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
review.
- Have you exhausted the health plan company's internal dispute resolution and appeal process?
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 health plan 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?
If you have exhausted your health plan's internal complaint and/or appeal process, you may seek external review immediately.
If not, you will first need to go through your health plan's internal complaint and/or appeal processes. It may take 30 days for the complaint process and another 30 - 45 days for the appeal process. Complaints involving medically related disputes only go through the appeal process. Disputes concerning benefits need to follow both the complaint and appeal procedures within the health plan.
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 health plan company enrollees. If the Department of Health determines that the health plan company is in violation of law, it can order compliance and take enforcement action against the health plan company for its violation, including administrative penalties. There is no filing fee for complaints filed with the State of Minnesota.
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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 40 days. Expedited decisions are also available, allowing for a decision within 3 days. The decision in each case is binding on the health plan company 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 40 days.
- Does the issue in your complaint affect other enrollees as well as
you?
Decisions reached by the independent review organization affect only you, the enrollee who filed the external review request. The State of Minnesota's decision can be enforced for all similarly affected enrollees. A health plan company 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 health plan company 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:
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Maximus CHDR
Eastgate Square
50 Square Drive, Suite 210
Victor, NY 14564-1099
Telephone: 1-585-425-5280
Web: www.maximus.com
Note: Minnesota law requires the state to periodically provide summary data about cases that have gone through external review. This summary data will not identify any individuals.
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