This includes the use of expert medical opinions. A decision is required no later than 40 days after receiving the request for review. The external review process must determine if an adverse medical decision was consistent with applicable statutory definitions of medical necessity. For issues not requiring medical necessity determinations, the review must determine if the health plan was in compliance with the enrollee's benefit plan. Decisions are binding on the health plan and non-binding on the enrollee, although a plan may seek judicial review on the grounds that the decision is arbitrary and capricious or an abuse of discretion.
External reviewers are immune from civil liability.
Data collecting and reporting is required and summary data on decisions is public information. This external review process does not apply to public benefit programs such as Medical Assistance or MinnesotaCare. A complaint is any grievance not the subject of litigation, that has been submitted to a health plan company. It does not include medical necessity determinations, which must follow the URO process described above. The plan must provide a complaint form to make written complaints.