Minnesota

Group plans. If you have a group health plan, you must first file a formal complaint with your health insurer before requesting an internal appeal.^[1] Your complaint may be submitted orally (by phone) or in writing directly to your health insurer.^[2] Your member handbook, contract, or certification of coverage must include clear directions on how to submit a complaint. You should follow those instructions.^[3] The complaint process may take up to 44 days to complete.^[4]

If your group health insurer denies your claim after submission of your complaint, you have the right to an internal appeal.^[5] This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:

• Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
• Collect information. In addition to the determination letter, collect all of the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
• Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
• Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
• Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
• Request an expedited appeal, if applicable. You can request an expedited appeal if your health care provider believes that your situation is urgent. In such case, ask your health care provider to call your insurer and ask for the expedited appeal.^[6]
• Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

Individual plans. If you have an individual health plan, you must file a formal complaint with your health insurer either orally (by phone) or in writing.^[7] Your member handbook, contract, or certification of coverage must include clear directions on how to submit a complaint, and you should follow those instructions for submitting your complaint.^[8] The complaint process may take up to 44 days to complete.^[9] If your complaint is denied, check to see if your insurer follows the internal appeals process.^[10] If it does, follow the instructions above for submitting internal appeals. Otherwise, when you receive notice of the denial of your complaint, your health insurer will include instructions regarding how to submit your claim to external review.^[11]

The internal appeals process should take a maximum of 45 days for both group and individual health plans.^[12] The expedited appeals process should take no longer than 72 hours after your health insurer receives the expedited appeal request.^[13]

During an external review, an independent third party reviews your insurer’s decision.^[14] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.

You can request an appeal in the following situations:

• Your group health insurer denies your internal appeal;
• Your individual health plan insurer follows the internal appeals process and your appeal is denied;^[15] or
• Your situation is urgent, in which case you would request an expedited external review.^[16]

Your situation is considered urgent if one of the following applies:

• Waiting up to 45 days to receive your requested treatment would seriously jeopardize your life, health, or ability to regain maximum function; or
• You are currently receiving inpatient emergency services, have not been discharged from the facility yet, and your requested treatment relates to the emergency services.^[17]

If you qualify for an expedited external review, you can request it at the same time that you request the expedited internal review.^[18]

You should file your request for an external review within six months from your insurer’s most recent decision.^[19] If your plan is a health maintenance organization (“HMO”), you should file your request with the Minnesota Department of Health. If your health insurer is an insurance company, you should file your request with the Minnesota Department of Commerce.^[20] The respective Departments will assign your case to an external review agency who will then notify you and your health insurer of the assignment and their review of your case.^[21]

Information. You can find the external review request form for HMO requests here and the request form for an insurance company here. You should include the following information in your request:

• The name, address, and telephone number of the enrollee;
• The name of the patient, if different than the enrollee;
• The enrollee’s identification number;
• If you are represented by another person, that person’s name, address, telephone number, and relationship to you; and
• The name and address of your health plan.^[22]

Supporting documents. You should also submit any new information or documentation that you did not previously include with your internal review request.^[23] Your insurer will also submit documentation related to your appeal.

Filing fee. There is a $25 filing fee for submitting the request which will be refunded if you are successful.^[24] If the filing fee would create a financial hardship, you can provide a written statement explaining why the fee would create such a hardship.

Submit for HMO. You can submit your HMO claim request by mail to:

Minnesota Department of Health
Attn: Managed Care Systems Section
P.O. Box 64882
St. Paul, MN 55164-0882^[25]

If you are requesting an expedited review, you can make the request by phone to the Department of Health at (651) 201-5100 or (800) 657-3916. If mailing an application for an expedited review would unreasonably delay the review, you should fax the application to (651) 201-5186 or email it to [email protected].

Submit for Insurance Claim. You can submit your insurance company claim request by mail to:

External Review Process
Minnesota Department of Commerce
85 7th Place East
St. Paul, MN 55101^[26]

If you are requesting an expedited review, you should fax the application to (651) 539-0105, email it to [email protected], or call the Department of Commerce at (651) 539-1600 or (800) 657-3602.

The external review process should take no more than 45 days after the case is received by the external review organization.^[27] If you requested an expedited external review, the process should no longer than 72 hours after your request is received.^[28]

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

Your complaint will be assigned to an investigator who will determine whether the HMO’s actions are in compliance with state law. If the Department suspects that the HMO has violated a law or regulation, the Department will refer your complaint for possible enforcement action, which may include a penalty or corrective action plan.^[32] Most investigations are completed within 30 to 60 days.^[33]

If your health plan is with an insurance company and your coverage is still denied after the external review process, you can file a complaint with the Minnesota Department of Commerce. Your complaint should include the following information:

• The name, address, email 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 name and address of the insurance company;
• The policy number, group number, certificate number, claim number, and date of loss/treatment;
• The name of the employer, if a group plan;
• The reason for the complaint; and
• A description of the problem.^[34]

You should submit the following documents as supporting information:

• A copy of your insurance card; 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;
• A copy of your insurance policy; and
• All responses from your insurer.^[35]

You can find a copy of the complaint form here. You can also submit your complaint and supporting documents online here or mail them to:^[36]

Minnesota Department of Commerce
Attn: Consumer Protection & Education Division
85 7^th Place East, Suite 500
St. Paul, MN 55101

The Department of Commerce will investigate your complaint and determine whether the insurance company is in compliance with state law. If the Department suspects that the insurer has violated a law or regulation, it can pursue enforcement action against the insurer.^[37]

You can contact the Minnesota Department of Health at (651) 201-5100 or (800) 657-3916. The Department of Health is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.

You can contact the Minnesota Department of Commerce at (651) 539-1600 or (800) 657-3602. The Department of Commerce is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.