"Request for External Appeal" - Minnesota

Request for External Appeal is a legal document that was released by the Minnesota Commerce Department - a government authority operating within Minnesota.

Form Details:

  • The latest edition currently provided by the Minnesota Commerce Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Minnesota Commerce Department.

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Download "Request for External Appeal" - Minnesota

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Commerce is here to help
consumer.protection@state.mn.us
mn.gov/commerce
651-539-1600 | 1-800-657-3602 (Greater MN)
Health insurance external review appeal
If you have a health insurance claim that continues to be denied by a health plan
company, you have the right to appeal that denial. Minnesota law requires your insurer to
notify you of your right to an external appeal review by the Minnesota Department of Commerce.
External Appeal
This External Appeal will be performed by a state approved contract vendor. Its employees and physicians are impartial,
separate from, and has no affiliation with any health plan.
The result of an External Appeal is nonbinding on you, the insured, but it is binding on the health plan company. (If you
lose, you have the right to appeal the decision in court. If the health plan company loses, it cannot appeal the decision.)
If you wish to file an appeal for an external review, please complete the attached application and attach the
$25.00 filing fee made payable to the Minnesota Department of Commerce. We will forward your application to
a state approved contract vendor.
If you wish to claim financial hardship and not pay the $25.00 filing fee, please provide a written explanation as to
why the filing fee would be a financial hardship.
Mediation Option (not available for expedited cases):
Most appeals are based on written information submitted by you and the health plan company. In mediation, however,
you and the health plan company talk about the appeal and try to resolve it (by phone or in person) with a trained
mediator.
If both you and the health plan company request mediation, a state approved contract vendor decides if mediation is
appropriate for your case.
All applications should be sent to:
External Review Process
Minnesota Department of Commerce
85 7th Place East St. Paul, MN 55101
Questions or assistance:
Call 1-800-657-3602 or 651-539-1600
Select the Insurance option (choice #3) on telephone message to speak with an insurance investigator who can assist
you.
Commerce is here to help
consumer.protection@state.mn.us
mn.gov/commerce
651-539-1600 | 1-800-657-3602 (Greater MN)
Health insurance external review appeal
If you have a health insurance claim that continues to be denied by a health plan
company, you have the right to appeal that denial. Minnesota law requires your insurer to
notify you of your right to an external appeal review by the Minnesota Department of Commerce.
External Appeal
This External Appeal will be performed by a state approved contract vendor. Its employees and physicians are impartial,
separate from, and has no affiliation with any health plan.
The result of an External Appeal is nonbinding on you, the insured, but it is binding on the health plan company. (If you
lose, you have the right to appeal the decision in court. If the health plan company loses, it cannot appeal the decision.)
If you wish to file an appeal for an external review, please complete the attached application and attach the
$25.00 filing fee made payable to the Minnesota Department of Commerce. We will forward your application to
a state approved contract vendor.
If you wish to claim financial hardship and not pay the $25.00 filing fee, please provide a written explanation as to
why the filing fee would be a financial hardship.
Mediation Option (not available for expedited cases):
Most appeals are based on written information submitted by you and the health plan company. In mediation, however,
you and the health plan company talk about the appeal and try to resolve it (by phone or in person) with a trained
mediator.
If both you and the health plan company request mediation, a state approved contract vendor decides if mediation is
appropriate for your case.
All applications should be sent to:
External Review Process
Minnesota Department of Commerce
85 7th Place East St. Paul, MN 55101
Questions or assistance:
Call 1-800-657-3602 or 651-539-1600
Select the Insurance option (choice #3) on telephone message to speak with an insurance investigator who can assist
you.
Commerce is here to help
consumer.protection@state.mn.us
mn.gov/commerce
651-539-1600 | 1-800-657-3602 (Greater MN)
Request for External Appeal
Enrollee/Insured Information
Enrollee/Insured Phone
Enrollee/Insured Name:
Dependent Name (if appeal is on behalf of a dependent):
Day (
)
Other: (
)
Enrollee/Insured ID #:
Enrollee/Insured Address:
E-Mail:
City:
State:
Zip Code:
You have the right to choose a person to represent you in your appeal. You must complete and sign the following
section to appoint a representative.
Enrollee/Insured Representative Information
Representative Name:
Representative Phone: (
)
Relationship to Enrollee/Insured:
Fax: (
)
Representative Address:
I am the enrollee/insured identified above and I authorize the person designated above to represent me in my
external appeal.
Enrollee/Insured Signature:
Health Plan or Utilization Review Company Information (Enter the name of the company that
denied your claim) Health Plan Name:
Plan Address:
Contact Person Phone: (
)
Contact Person (If known to enrollee/insured):
Summary of Appeal
(Enter a brief description of the claim or the request for treatment or service that was denied, why you are appealing this
denial, and/or attach a copy of the denial.)
Commerce is here to help
consumer.protection@state.mn.us
mn.gov/commerce
651-539-1600 | 1-800-657-3602 (Greater MN)
Appeal Filing Fee
(You must pay a fee of $25, unless you are applying for a hardship waiver.)
Yes, I have enclosed a check for $25, made payable to Minnesota Department of Commerce.
No, I am applying for a hardship waiver. (Provide a written explanation stating why the fee would be a financial
hardship. Examples of financial hardship could be the size of your family and income, unusual or unexpected expenses,
recent change in family circumstances or change in employment status, etc.)
Expedited (Fast, 72-hour) Appeal.
(This type of appeal is not required by law. The Department of Commerce encourages, but cannot require, your insurance
company to participate.) A normal appeal can take 40 days. If you believe a 40-day wait could harm your health, or the health
of the person you are representing, you may get an expedited 72-hour appeal. You can
provide the request for an expedited appeal by phone call or fax. You must provide the information requested on the
application and fax (651-539-0105), e-mail (consumer.protection@state.mn.us) or phone (651-539-1600 or 800- 657-3602) the
request to the Department of Commerce.
Assistance and Counseling
If you have questions about this external appeal process, contact the State of Minnesota Department of Commerce at 800-657-
3602 or the State’s External Review provider.
Information on Use of Data
The information you are providing is needed to process your request for external review, and to forward the information to a
state approved contract vendor. You are not legally required to provide any private or confidential data to an approved vendor
or the Department of Commerce and you may refuse to provide any data. However, failure to provide requested data could
affect the decision of your appeal. If the Department of Commerce identifies the need to conduct its own investigation of your
complaint, we will contact you directly to discuss our investigation process and obtain any necessary information.
Signature and Release of Person Requesting Appeal
All of the information on this form is true to the best of my knowledge. I am insured in the above health plan company and that
I have gone through my health plan company’s internal appeal process. I authorize my health plan company and my medical
providers to release my medical records to CHDR solely for the purpose of reviewing my appeal. This consent will be revoked
upon the conclusion of the external review and appeal. I authorize the Department of Commerce to forward any documents
connected to my external review appeal to a state approved contract vendor.
Insured or Representative Signature
Date
Mail or fax application to:
External Appeals Process, Minnesota Department of Commerce
85 7th Place East St. Paul, MN 55101
Fax number: 651-539-0105
If you have any questions about the external appeals process or the application, please contact the Consumer Services Center
at 800-657-3602 or 651-539-1600.
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