Options For Challenging A Health Plan Decision
For Minnesotans Covered By Fully-Insured Health Plans

Option #1:
File an appeal with your health plan.

• Patients have the right to appeal using the health plan's state-mandated internal appeals process
• Patients have the right to a hearing if they request one
• State law and accreditation standards specify procedural rights and deadlines, including an expedited process of urgent medical matters
• An appeal can be filed at any time

• Patients have the right to file a complaint with a state regulatory agency
• The state has the power to investigate and overturn a health plan's decision
• A complaint can be filed with a regulatory agency at any time
• Regulatory agencies have the power to impose fines or revoke a health plan's license

Option #3:
Obtain an external review.

• Patients may obtain an external review, including a review by a qualified, independent medical professional
• State law established procedures and deadlines for external review
• Health plans must honor the external review determination
• A health plan member or a person acting on his/her behalf can request external review
• The External Review Organization is selected by the state and must be free of any conflicts of interest
• The external review decision is binding on the health plan, but not on the member
• Alternative dispute resolution is used for non-medical appeals
• Disputes involving medical issues are referred for an independent medical review by a qualified medical professional or medical panel
• Expedited review is available if a patient's health care professional believes it is needed, in which case a decision must be rendered as quickly as the patient's condition requires
• External review costs are paid by the health plan, except for a $25 filing fee that may be waived in cases of financial hardship