HMO Complaint and Appeals Options, Forms and Process

There are several reasons when an enrollee is dissatisfied with a decision made by his or her health maintenance organization (HMO). The issue may be simple or complex and may relate to past, current or future health care. Either way, if you have been denied care, feel your rights have been infringed upon, or are dissatisfied with how you have been treated or served - you have options.

1.  Health maintenance organization internal complaint and appeal - Minnesota law requires each HMO to establish an internal process whereby enrollees can complain about any action taken by their HMO. The complaint process can be initiated via phone call or written communications to the HMO's member service department. If the enrollee's complaint is not resolved to his or her satisfaction, the enrollee has the right to file an appeal with the HMO. Both complaint and appeal process are provided at no cost to enrollees.

2.  Minnesota Department of Health complaint - HMO enrollees have the right to file complaints with the Minnesota Department of Health. The complaint process can be initiated via phone call or written communication. We can investigate to determine if the HMO and its providers have acted consistent with applicable law and with the terms of the enrollee's health plan. Our investigation can take place at the same time as the HMO's internal complaint and appeal process. There is no cost to file a complaint with the Minnesota Department of Health.

3.  External Review - The State of Minnesota contracts with up to three independent third parties that can provide an appeal for HMO enrollees who are dissatisified with the HMO's internal complaint and appeal decision. Beginning January 1, 2014, for those enrolled in an individual health plan, external review is available when the decision on a complaint is against the enrollee. For those enrolled in a group plan, external review is available after the decision on an appeal is against the enrollee. There is a $25 fee for each External Review unless it is waived for hardship. If the decision is favorable to the enrollee, the $25 fee is refunded.

Please note that for those enrolled in a grandfathered individual health plan, you must first receive an unfavorable appeal decision before seeking external review.

4.  Pursue Legal Action - You always have the right to seek legal counsel or to have an attorney assist you in pursuing your complaint and appeal options. However, once litigation has begun, the Department of Health can no longer investigate your complaint.

For more information, or to file a complaint, contact MCS section at (651) 201-5100 or 1-800-657-3916.

Updated Thursday, February 19, 2015 at 08:05AM November 2013