Managing Your Health Care

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:

1. 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.
2. Include documentation. In particular, ask your physician to write a letter supporting your position, using relevant language from the contract, if possible. 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.
3. If you attend an in-person appeal hearing, bring a friend, family member, or an attorney to help you.
4. 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 an 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 of Minnesota, it must participate in the external appeals process.

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 the section titled Private Health Care 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. 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/agencies/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
Consumer Helpline
85 7th Place East, Suite 280
St. Paul, MN 55101
(651) 539-1600 (local)
(800) 657-3602 (Greater MN only)
www.mn.gov/commerce

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
Managed Care Systems Section
P.O. Box 64882
Saint Paul, MN 55164-0882
(651) 201-5100 or (800) 657-3916
www.health.state.mn.us/facilities/insurance/managedcare/planinfo/hmo.html

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
Consumer Helpline
85 7th Place East, Suite 280
St. Paul, MN 55101
(651) 539-1600 (local)
(800) 657-3602 (Greater MN only)
www.mn.gov/commerce

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 Minnesota Attorney General’s Office for help. In addition, you may also contact the Attorney General’s Office concerning coverage or other issues as follows:

Office of Minnesota Attorney General Keith Ellison
445 Minnesota Street, Suite 1400
St. Paul, MN 55101
(651) 296-3353 (Twin Cities Calling Area)
(800) 657-3787 (Outside the Twin Cities)
(800) 627-3529 (Minnesota Relay)

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 health contract.

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:

Minnesota Department of Health
Office of Health Facility Complaints
300 Golden Rule Building
P.O. Box 64970
St. Paul, MN 55164-0970
(651) 201-4200 or (800) 369-7994
www.health.state.mn.us/facilities/regulation

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: