HMO Enrollee External Appeals and Complaints
Complaint Process
If you are unhappy with a decision made by your Health Maintenance Organization (HMO), or how you were treated by your HMO, you can file a complaint with the Minnesota Department of Health (MDH). The decision from your HMO can be related to your HMO not covering services you think should be covered, not paying claims you think should be paid, or if you think you were asked to pay more than you should. You can also file a complaint if you believe your access to providers is limited, or if you are not happy with how you have been treated or served by your provider or clinic/hospital.
HMO complaints can happen at the same time as an internal complaint or appeal with the HMO.
HMO Complaints Options
- Health Maintenance Organization internal complaint - Minnesota law requires each HMO to establish an internal process whereby enrollees can complain about any action taken by their HMO. An enrollee or their representative can start the complaint process with a phone call or written communication to the HMO’s Member Services Department. The complaint process is provided at no cost to enrollees.
- Minnesota Department of Health complaint - HMO enrollees have the right to file complaints with MDH. MDH can investigate to determine if the HMO and its providers have acted consistently with applicable law and with the terms of the enrollee's health plan. There is no cost to file a complaint with the Minnesota Department of Health. An enrollee or their representative can start the complaint process by:
- 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.
Use of Artificial Intelligence (AI)
If you use AI to assist in preparing documents or information submitted, please carefully review all materials prior to submission. AI-generated content frequently contains inaccuracies, incomplete information, or incorrect references to laws, regulations, or policy provisions that may not be applicable to your specific circumstances. Submission of inaccurate, repetitive, or irrelevant information may delay or complicate our office’s ability to efficiently review and investigate the matter and may result in longer response times.
Frequently Asked Questions about HMO Complaints
