HMO Enrollee External Appeals and Complaints 
Quality of Care Complaints

Minnesota law requires each health maintenance organization (HMO) to have a quality of care complaint investigation process. “Quality of care” means an expressed dissatisfaction regarding health care services resulting in potential or actual harm to a patient. Some examples of quality of care issues include concerns about a provider and/or staff’s competence, knowledge or skill; clinical appropriateness of care; behavior/attitude; communications; and other factors that could impact the quality of health care services.  

You can file a quality of care complaint by using the HMO Complaint Form (PDF).

Please note, quality of care complaints are peer reviewed. Peer reviewed records are confidential by law - Minn. Stat. §145.64. This means that neither you nor your representative can see the results of the Health Maintenance Organization (HMO) peer review process. The Minnesota Department of Health has the authority to review the health plans complete peer review file, but we are also prohibited from providing you with information about this file.

Quality of Care complaint process:

1. The investigator gathers information from you and other parties. We will direct your health plan to conduct a quality of care investigation. We will notify you that your complaint has been forwarded to your health plan for an investigation.
2. Once the health plan has completed its review, it will send its findings to MDH. Your plan must: 
    
   1. address and evaluate each issue or allegation 
   2. use evidence to support the conclusion of the investigation 
   3. conduct a medical director review, if necessary
   4. have a proper record keeping system
   5. ensure that corrective actions resolve the issue

The Department can take action against an HMO for its failure to conduct an appropriate internal quality assurance review. Action may include an administrative penalty up to $25,000.

Minnesota Health Professional Licensing Boards and Contact Information

While MCS cannot take action against a licensed provider, you may be able to file a complaint with one of the licensing entities listed below. Licensed health professionals such as physicians, nurses and psychologists are regulated by separate licensing boards. Complaints about specific health professionals can be filed with their respective licensing board. Some frequently called licensing boards are: 

• Minnesota Board of Psychology, 612-617-2230
• Minnesota Board of Chiropractic Examiners, 651-201-2850
• Minnesota Board of Dentistry, 612-617-2250
• Minnesota Board of Medical Practice, 612-617-2130
  (Physicians, Physician Assistants, Physical Therapists)
• Minnesota Nursing Board, 612-317-3000
  (RNs, LPNs, Midwives, Nurse Practitioners)
• Minnesota Board of Social Work, 612-617-2100
• Minnesota Office of Emergency Medical Services (OEMS)
• Minnesota Board of Behavioral Health and Therapy, 651-201-2756
• Minnesota Board of Occupational Therapy Practice, 612-548-2179
• Minnesota Board of Optometry, 651-201-2762
• Minnesota Board of Dietetics and Nutrition Practice, 651-201-2764
• Minnesota Board of Pharmacy, 651-201-2825
• Minnesota Board of Physical Therapy, 612-627-5406
• Minnesota Board of Podiatric Medicine, 612-548-2175
• Minnesota Board of Executives for Long-Term Services and Supports (BELTSS), 651-201-2730
• Minnesota Board of Marriage and Family Therapy, 612-617-2220 

Some health occupations, such as speech pathologists, audiologists, hearing aid dispensers, and unlicensed complimentary health practitioners, are regulated by the Health Occupations Program (HOP) at the Department of Health. That program can investigate complaints about these practitioners. For further information contact HOP at (651) 201-4200.