State of Minnesota
More about
Attorney General
Lori Swanson


Minnesota Attorney General's Office

1400 Bremer Tower
445 Minnesota Street
St. Paul, MN 55101

(651) 296-3353
(800) 657-3787

M - F 8 am - 5 pm

TTY:(651) 297-7206
TTY:(800) 366-4812

III. Appeals, Grievances and Complaints

INTERNAL APPEALS

Most health plans provide a way for you to file an internal grievance or appeal. These procedures are described in your contract with the health plan and may contain multiple steps to follow. If you decide to use these procedures, here are a few steps to keep in mind

  • Explain clearly why you believe you are right and the health plan is wrong. Where possible, point to language in your contract that supports your position.

  • Include documentation. In particular, ask your physician to write a letter supporting your position. The physician should state why he or she believes your position is correct and why the facts of your particular medical condition entitle you to coverage.

  • If you attend an in-person appeal hearing, bring an ally with you. Bring a friend, family member or an attorney to help you.

  • Keep in mind that most grievance and appeal procedures are internal health plan mechanisms. They may be controlled by the same people, or colleagues of the same people, who have already said "no" once. Also, even a so-called "independent" hearing officer is often paid by the health plan. This "independent" hearing officer often has a contract with the health plan and conducts appeals at the health plan's premises.

 

EXTERNAL APPEALS

If you are unhappy with the result of the internal appeal or have been told that a utilization review organization has refused to certify certain health care services, you may appeal to an external review entity. You should receive notice from the health plan company about your right to external review when a health plan company denies your request.

You may request external review by filing a written request for external review with the Minnesota Department of Health if the health plan company is an HMO, or with the Minnesota Department of Commerce if the health plan company is an insurance company. There is a $25 filing fee for an external appeal, but that fee may be waived if it is a financial hardship. Once you have filed an external appeal the external review organization will notify you of its process and you may submit whatever documents and argument you want the review organization to consider.

The decision of the external review organization is binding on the health plan company, but not on you. Thus, you could attempt to further challenge the decision by, for example, going to court. The health plan company can challenge the result in court only on the grounds that the decision of the external review organization is arbitrary or an abuse of discretion. If the health plan company is regulated by the State, it must participate in the external appeals process.

 

SPECIAL NOTE ON ERISA PLANS

The Employee Retirement Income Security Act of 1974 (ERISA) applies to certain employer-sponsored health plans. ERISA requires these plans to include an appeal mechanism, but it also allows plans to limit the time in which you must file your appeal.  You may have as little as 60 days to appeal, and you must exhaust this appeal process before you can go to court.  You should carefully read the provisions so you don't miss any deadlines.  The provisions should be explained in your contract.

 

MAKING A COMPLAINT TO A GOVERNMENT AGENCY

If you are interested in making a complaint to a regulatory or government agency, you should first determine the type of health plan you have. Refer to "Private Health Coverage" to determine if you have a fully-insured or self-insured plan and are covered by an HMO or insurance company. The following agencies accept complaints concerning your health care coverage.

  • SELF-INSURED PLANS

    The United States Department of Labor Employee Benefits Security Administration (“EBSA”) regulates self-insured plans. The State of Minnesota does not have authority to directly regulate self-insured plans. If you have a complaint regarding your self-insured plan, you may contact the EBSA as follows:

    Employee Benefits Security Administration
    Kansas City Regional Office
    2300 Main Street, Suite 1100
    Kansas City, MO 64108
    816-285-1800 or 866-444-EBSA (3272)
    www.dol.gov/ebsa

    The Minnesota Department of Commerce regulates third-party administrators doing business in Minnesota. If your self-insured plan uses a third-party administrator, you may contact the Minnesota Department of Commerce with a complaint as follows:

    Minnesota Department of Commerce
    85 East 7th Place, Suite 500
    St. Paul, MN 55101
    (651) 539-1500
    www.commerce.state.mn.us


  • FULLY-INSURED PLANS

    If your health coverage is through an HMO, you may contact the Minnesota Department of Health concerning coverage issues as follows:

    Minnesota Department of Health
    85 East Seventh Place, Suite 400
    Saint Paul, MN 55101
    651-201-4201
    www.health.state.mn.us External Link

    If your health coverage is through a health insurance company, you may contact the Minnesota Department of Commerce concerning coverage issues as follows:

    Minnesota Department of Commerce
    85 East 7th Place, Suite 500
    St. Paul, MN 55101
    (651) 539-1500
    www.commerce.state.mn.us

    The bureaucracy can be confusing — if you are unsure if your plan is self-insured, fully-insured, through an HMO or an insurance company, contact the Attorney General’s Office for help. In addition, you may also contact the Attorney General’s Office concerning coverage or other issues as follows:

    Minnesota Attorney General's Office
    1400 Bremer Tower
    445 Minnesota Street
    St. Paul, MN 55101
    (651) 296-3353 or 1-800-657-3787
    TTY: (651) 297-7206 or TTY: 1-800-366-4812

  • OTHER TYPES OF COMPLAINTS

    If you would like to make a complaint about a licensed hospital, nursing home, boarding care home, supervised living facility, assisted living or home health agency, you may contact the Minnesota Department of Health, Office of Health Facility Complaints as follows:

    Office of Health Facility Complaints
    P. O. Box 64970
    St. Paul, MN 55164-0970
    651-201-4201 or 800-369-7994

    If you have a complaint about a health care professional, the State of Minnesota has several boards that license different medical professions, including the following:

    Minnesota Board of Chiropractic Examiners
    2829 University Avenue SE, Suite 300
    Minneapolis, MN 55414-3220
    651-201-2850
    www.mn-chiroboard.state.mn.us

    Minnesota Board of Dietetics and Nutrition Practice
    2829 University Avenue SE, Suite 555
    Minneapolis, MN 55414
    651-201-2764
    www.dieteticsnutritionboard.state.mn.us

    Minnesota Board of Emergency Medical Services
    (for ambulance services)
    2829 University Avenue SE, Suite 310
    Minneapolis, MN 55414
    651-201-2800
    www.emsrb.state.mn.us

    Minnesota Board of Examiners for Nursing Home Administrators
    2829 University Avenue SE, Suite 560
    Minneapolis, MN 55414-4202
    651-201-2730
    www.benha.state.mn.us

    Minnesota Board of Optometry
    2829 University Avenue SE, Suite 550
    Minneapolis, MN 55414
    651-201-2762
    www.optometryboard.state.mn.us

    Minnesota Board of Nursing
    2829 University Avenue SE, Suite 200
    Minneapolis, MN 55414-3253
    612-317-3000
    www.nursingboard.state.mn.us

    Minnesota Board of Pharmacy
    2829 University Avenue SE, Suite 530
    Minneapolis, MN 55414-3251
    651-201-2825
    www.phcybrd.state.mn.us

    Minnesota Board of Physical Therapy
    2829 University Avenue SE, Suite 420
    Minneapolis, MN 55414
    612-627-5406
    www.physicaltherapy.state.mn.us


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