MDH HMO Enrollee Complaint and External Review Process

MDH HMO Enrollee Complaint and External Review Process

There are several reasons why an enrollee may be dissatisfied with a decision made by their health maintenance organization (HMO). The issue may be simple or complex and may relate to past, current or future health care claims. If you have been denied coverage, believe your access to providers is limited 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. Print and complete HMO complaint form (PDF)
    Download and print a paper copy of the form to be completed and mailed back to MDH.

    Print and/or complete HMO complaint form (Word)
    Download and complete electronically, then email or mail a copy to MDH.

    The assigned investigator reviews the complaint to determine: the nature of the complaint and the desired resolution; whether the issue falls within the jurisdiction of the Department of Health or should be referred to another agency; what information is needed to investigate this complaint; whether the decision or action of the health plan relative to the complainant's issue is in compliance with the applicable statutes, rules, and the enrollee's certificate of coverage; and what actions, if any, are necessary to bring the HMO into compliance with applicable law or rule and the enrollee's certificate of coverage.

    Investigations are conducted in accordance with the Minnesota Government Data Practices Act and most are completed within 30 - 60 days.

    At the conclusion of the investigation, the investigator informs the complainant of the investigation via letter and/or phone contact.

    If a violation of law, rule or contract is suspected, the complaint will be referred for possible enforcement action which may include a penalty and/or a corrective action plan.

    Most investigations relate to an HMO’s processing and coverage of medical claims and benefits. In some cases, an enrollee may have a complaint about a medical provider. Issues concerning provider care may be submitted to MCS as quality of care complaints. Read more about quality of care complaints.

  4. Apply for an External Review -The State of Minnesota contracts with up to three independent third parties that can provide an appeal for HMO enrollees who are dissatisfied with the HMO's internal complaint and appeal decision. 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.

  5. 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.

Updated Thursday, 23-Dec-2021 12:08:15 CST