Minnesota Attorney General's Office
1400 Bremer Tower
445 Minnesota Street
St. Paul, MN 55101
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Points On Internal Grievances and Appeals
STEPS TO KEEP IN MIND
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.
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.
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