If your health plan is an HMO and your coverage is still denied after the external review process, you can file a complaint with the Minnesota Department of Health. You can find a copy of the complaint form here. Your complaint should include the following information:

• The name, address, and telephone number of the person filing the complaint (“Complainant”);
• The Complainant’s relationship to the insured individual;
• The name of the insured individual, if different than the Complainant;
• The date of birth of the insured individual;
• The name of a family member you would like to be interviewed regarding the complaint (optional);
• The name of health plan;
• The type of coverage;
• The enrollee/membership number and date of incident;
• The name of the insured individual’s primary care physician; and
• The details of the complaint; and
• What you consider to be a fair resolution.^[29]

You should also submit the following supporting documents:

• A signed medical records release form (found in the complaint application);
• A copy of your insurance card;
• Any referrals, denials, or prior authorizations;
• Copies of coverage denials or adverse benefit determinations from your insurer;
• Copies of any determinations made by internal and external reviewers;
• Any materials submitted with prior appeals and complaints;
• Supporting documentation from your doctor;
• Copies of any bills and explanations of benefits;
• A copy of your insurance policy; and
• All responses from your insurer.^[30]

The completed form and supporting documents can be faxed to (651) 201-5186, emailed to [email protected], or mailed to:^[31]

Minnesota Department of Health
Managed Care Section
P.O. Box 64882
St. Paul, MN 55164-0882