What is external review?
External reviewis an independent review of the plan's adverse determination after internal appeal (or complaint) is complete. Minnesota assigns a state-contracted external review entity to review medical and coverage disputes under Minn. Stat. § 62Q.73.
MDH or Commerce facilitates the process and randomly assigns the reviewer; the department does not make the medical decision itself. The plan pays for the review—you should not be charged a filing fee.
General overview: Appeals roadmap. Complete Minnesota internal appeals first unless an exception applies.
Who can use Minnesota review?
External review generally applies when:
- You have a Minnesota-regulated health plan (fully insured individual, small group, or HMO)
- You received an adverse determination after internal complaint/appeal (or qualify under § 62Q.73, subd. 1)
- You file with the correct commissioner—MDH for health plan companies it regulates (most HMOs), Commercefor insurers it regulates (many indemnity/accident & sickness carriers)
Usually does not apply to:
- Self-funded ERISA employer plans (U.S. Department of Labor)
- Medical Assistance, MinnesotaCare, and Medicare (§ 62Q.73, subd. 2)—separate appeal systems
- Grandfathered individual plans that use alternate definitions (§ 62Q.73, subd. 1(2))
Deadlines & exhaustion
6-month filing window
Request external review within 6 months of the adverse determination (§ 62Q.73, subd. 3(d)). Your denial letter should also state this right.
Exhaust internal appeals first
- Group plans: complete internal appeal under § 62Q.70 after an adverse complaint decision
- Many individual plans: adverse complaint decision under § 62Q.69 may be enough to request external review (§ 62Q.73, subd. 1(1))
- PA denials: complete internal PA appeal under § 62M.06 first
Expedited external review is available when delay would seriously jeopardize life, health, or ability to regain maximum function—including when you simultaneously requested expedited internal appeal (§ 62Q.73, subd. 6(e)).
How to file
- Complete internal appeals and keep the final adverse determination letter.
- Gather medical records, the denial letter, and appeal correspondence.
- Submit a written external review request to the correct agency:
- Commerce (many insurers): email consumer.protection@state.mn.us or mail to External Review Process, Minnesota Department of Commerce, 85 7th Place East, St. Paul, MN 55101 — Commerce external review
- MDH (Minnesota HMOs): use the MDH external appeal form or portal — MDH HMO external appeal (health.mcs@state.mn.us or 651-201-5100 / 800-657-3916)
Links hub: Minnesota external appeals links.
How long it takes
- Each party has 10 business days to submit information after the reviewer is assigned (§ 62Q.73, subd. 6(a))
- Standard review: decision as soon as practical, but no later than 45 days after the request (§ 62Q.73, subd. 6(c))
- Expedited review: within 72 hours of receipt; written confirmation within 48 hours if first notice was oral (§ 62Q.73, subd. 6(e))
Medical issues are reviewed by a clinician with expertise in the condition (§ 62Q.73, subd. 6(b)).
Is the decision binding?
The external review decision is binding on the health plan but nonbinding on you—you may still pursue court review (§ 62Q.73, subd. 8). The plan may seek judicial review only on narrow grounds (arbitrary and capricious or abuse of discretion).
Optional mediation may be available for some Commerce-regulated cases if both you and the plan agree (not for expedited cases).
Medicaid & Medicare
Medical Assistance / MinnesotaCare: Use MCO appeal, then a DHS fair hearing under § 256.045—not § 62Q.73. In some MA appeals, DHS may arrange an expert medical opinion from the external review contractor ( § 62Q.73, subd. 2(b)).
Medicare & Medicare Advantage: Federal Medicare appeals through CMS—not Minnesota external review.
More: Medicaid managed care · Medicare appeals.