Filing Requirements for Health Carriers Seeking Approval of Provider Network Adequacy

Filing Requirements for Health Carriers Seeking Approval of Provider Network Adequacy

Note regarding networks to be offered in 2019: All network filings must be received by June 8, 2018.


  • Residential Treatment facilities should be reported in the provider network file as part of the network adequacy submission. NCQA defines “residential” treatment as “a facility or a discrete part of a facility that provides a 24 hour therapeutically planned and professionally staffed group living and learning environment to live-in residents who require psychiatric care or substance abuse treatment, but do not require acute medical care.” “Residential programs” are also defined in Minnesota Statutes, Section 245A.02, Subd. 14. Health carriers should use the “RT” provider type code for any provider facilities for which these definitions apply. A facility may meet the definition of Residential Treatment and may also provide Chemical Dependency or Substance Use Disorder Treatment. In this situation, the facility should be listed twice in the provider file, coded once as a Residential Treatment Facility (RT), and once as Chemical Dependency Inpatient (CD1F).
    • As part of the waiver request for all reason codes, a carrier must demonstrate with specific data that the geographic access standards cannot be met in a particular service area or part of a service area and also state what steps were and will be taken to address the network inadequacy (MN Statutes § 62K.10, subdivision 5). The waiver form requires health plan companies to both demonstrate and attest that good faith efforts were made to locate and contract with available providers in the area in which the waiver is requested. Health plan companies seeking waivers because no providers are available must demonstrate, with evidence -- including sources consulted—that there are no providers physically present in the area where the waiver is being requested. Health plan companies seeking waivers due to the inability to secure a contract must demonstrate, with evidence — including evidence that the health plan company has offered providers same or similar rates as other network providers — that the provider has refused to contract.

    General Instructions

    The "Minnesota Health Plan Market Rules" (“Market Rules”) outlined in Minnesota Statutes chapter 62K sets forth the requirements applicable to individual and small group health plans offered, sold, issued, or renewed in Minnesota beginning January 1, 2015. Unless otherwise exempted from Minnesota Statutes, chapter 62K, the Market Rules apply to all individual and small group health plans offered either outside or inside of the health insurance exchange.

    Under Minnesota Statutes 62K.10 all health carriers that offer health plans that require an enrollee to use or that create incentives, including financial incentives, for an enrollee to use a designated provider network must assure that providers in the designated network are geographically accessible to all potential enrollees within the health plan’s defined service area. Provider networks must be structured so that maximum travel distance or time for an enrollee to the nearest primary care, mental health or general hospital services to be the lesser of 30 miles or 30 minutes. In addition, the maximum travel distance or time for an enrollee to specialty physician services, ancillary services, specialized hospital services, or other types of services must be the lesser of 60 miles or 60 minutes.

    All networks that are offered, sold, issued, or renewed and offered either on or off the Health Care Exchange must submit each distinct network for approval. This requirement applies to any “health carrier” as defined under Minnesota Statutes chapter 62A.011 including insurance companies and health maintenance organizations (HMOs).

    Reminder: Legislative Changes that remain in effect from Plan Year 2018:

    • For those counties in which a health carrier actively markets an individual health plan, the health carrier must offer, in the same counties, at least one individual health plan with a provider network that includes in-network access to more than a single health care provider system. Minn. Stat. §62K.10 subd. 1a, See 2017 Session Laws, Chapter 13. This requirement may not be waived. A new Health System Access Template has been added to the plan management supporting documents tab in the System for Electronic Rate and Form Filing (SERFF) to demonstrate compliance with this new requirement. This template must be submitted in the Individual binder along with other form filings submitted by the carrier that is offering individual health plans. All health care systems included in network must be fully reflected in the Provider Network File submitted to the Provider Network Adequacy system.

    • Appeal of waiver of network adequacy requirements (Minn. Stat. § 62K.10): Modification of Minn. Stat. §62K.10, inserts a new subdivision, which allows providers, “aggrieved by the issuance of the waiver” granted by the Commissioner of Health under Minn. Stat. §62K.10, subd. 5 to appeal the waiver granted using the contested case procedures under Minnesota Statutes, Chapter 14. The new language stipulates that a, “contested case proceeding must be initiated within 60 days after the date on which the commissioner grants a waiver.” Without further guidance in the legislation, the Department of Health interprets this to mean that waivers are granted upon approval of the provider network, and concurrent with the final approval of premium rates. To make the intent of this statute actionable, all approved provider network waiver requests will be posted on the Minnesota Department of Health website concurrent with the posting of provider network service areas and premium rates. If a waiver is nullified through a contested case proceeding and no judicial review is sought, the health carrier must submit a modified provider network filing within 30 days after the deadline for seeking judicial review.

    Network adequacy data is nonpublic until the network is both approved by the Minnesota Department of Health (MDH), and the corresponding rates are approved in the plan management binder within the System for Electronic Rate and Form Filing (SERFF). While MDH does not publish lists of providers, if MDH receives a data practices request for this information after the public date, MDH will provide the data. The approved provider network lists are not considered trade secret under Minn. Stat. 13.37.

    Creating an Account under the MDH Network Adequacy System

    In order to begin this process you must first submit a binder through the SERFF system and obtain a Network ID (MNN#). The Network ID is generated in SERFF and can be found in the Network Template in your SERFF Binder. Instructions to create a filing through SERFF can be found at When creating an account in the PNA System, it must match the same network name as used in SERFF.

    Once a Network ID is obtained, and an account is created, you will be sent an email containing a password to enable you to upload all necessary documents. To create an account, follow the prompts at the following link: Provider Network Adequacy system.

    If you intend to submit network information related to a new network during a non-renewal period, please contact network adequacy staff at or contact the Managed Care Systems Section at 651-201-5165.

    Documents Required to be submitted to the Provider Network Adequacy (PNA) System for review for each Network

    Documents that are required for Network Adequacy Review include the following:

    Detailed instructions for all carriers to submit required information can be found at: Provider Network Adequacy Instructions (PDF).

    Essential Community Provider (ECP) Requirements for Provider Networks

    Filings submitted must meet requirements for inclusion of Essential Community Providers (ECPs). These requirements are intended to ensure that networks include a broad range of ECPs to serve the unique needs of certain populations. Minnesota requirements are based on ECP standards developed for Federally-Facilitated Exchanges. Consistent with guidance to issuers in the Federally Facilitated Exchange (FFE), issuers must include a minimum of 20 percent of designated Essential Community Providers (ECPs) in the provider network service area.

    The Provider Network Adequacy Instructions (page 11) will provide detailed instructions related to this requirement.

    Information specific to Stand-alone Dental Network Filings - Limited-Scope Pediatric Dental Plans

    Dental carriers that wish to be certified as Qualified Dental Plans (QDPs), also known as Stand Alone Dental Plans (SADPs), must submit networks for approval. Specific requirements for QDP’s can be found in the Provider Network Adequacy Detailed Instructions (page 12). SADPs must include a minimum of 20 percent of designated Dental ECPs in the service areas for SADPs

    See detailed Provider Network Adequacy Instructions (PDF) for further details and instructions.

Wednesday, June 06, 2018 at 02:45PM