MDH HMO Enrollee External Appeals and Complaints
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:
- To learn more about and to file an external appeal, visit HMO Enrollee External Appeal Process.
- To learn more about and to file a complaint, visit HMO Complaint Process.
- To learn more about the No Surprises Act and how to file a complaint, visit The No Surprises Act: New Protections from Surprise Billing.
Should I submit a complaint to the Minnesota Department of Health or request an appeal?
In making this decision, you may want to consider the following factors:
How long can you wait for a decision?
The Minnesota Department of Health (MDH) recommends you start with an appeal through your HMO. Complaints filed through your HMO can take up to 45 days to resolve. For an external appeal, you must first file a complaint through your HMO. After your appeal with your HMO, external appeals may also take up to 45 days.
However,72-hour, expedited external appeals are available in situations where the HMO’s denial could harm your health. HMOs also have an expedited appeal option.
Complaints filed with the MDH do not have a limit on how long they take, and do not require you to file an appeal with your HMO first.
How long has it been since your HMO made the decision you disagree with?
External appeal requests must be filed within six months of the decision you are appealing. After six months, you only have the right to file a complaint with the Minnesota Department of Health (MDH).
Does your complaint involve issues of complex, unproven, experimental or investigative medical treatment or otherwise require expert medical advice?
If so, consider filing an external appeal. MDH contracts with Independent Review Organizations who have readily available medical experts who will make a decision within 45 days. Expedited decisions are also available, allowing for a decision within 72 hours. The decision must be based on all documents submitted.
Does the issue in your complaint affect other enrollees as well as you?
Decisions reached in appeal affect only the enrollee who filed the appeal request. If the issue might impact other enrollees, consider filing a complaint. MDH can enforce decisions beyond a single enrollee, and an HMO can appeal the State of Minnesota's decision through an administrative hearing and ultimately to state court.
I don't know anything about the law. How do I know that my complaint is a legal issue or that it is handled correctly?
MDH has experience investigating complaints filed by HMO enrollees. The staff understand state laws that govern Minnesota health plan companies. If you aren’t sure, you can always contact the MDH, and they can help you determine which option is best.