AI-assisted research summary: Health plan companies must give enrollees a clear explanation of complaint and appeal procedures and related external review rights, with a limited alternative format if no member handbook is issued.
Each health plan company shall provide to enrollees a clear and concise description of its complaint resolution procedure, if applicable under section 62Q.68, subdivision 1, and the procedure used for utilization review as defined under chapter 62M as part of the member handbook, subscriber contract, or certificate of coverage. If the health plan company does not issue a member handbook, the health plan company may provide the description in another written document. The description must specifically inform enrollees: (1) how to submit a complaint to the health plan company; (2) if the health plan includes utilization review requirements, how to notify the utilization review organization in a timely manner and how to obtain authorization for health care services; (3) how to request an appeal either through the procedures described in section 62Q.70, if applicable, or through the procedures described in chapter 62M; (4) of the right to file a complaint with either the commissioner of health or commerce at any time during the complaint and appeal process; (5) of the toll-free telephone number of the appropriate commissioner; and (6) of the right, for individual and group coverage, to obtain an external review under section 62Q.73 and a description of when and how that right may be exercised, including that under most circumstances an enrollee must exhaust the internal complaint or appeal process prior to external review. However, an enrollee may proceed to external review without exhausting the internal complaint or appeal process under the following circumstances: (i) the health plan company waives the exhaustion requirement; (ii) the health plan company is considered to have waived the exhaustion requirement by failing to substantially comply with any requirements including, but not limited to, time limits for internal complaints or appeals; or (iii) the enrollee has applied for an expedited external review at the same time the enrollee has applied for internal review under chapter 62M.