Health Maintenance Organization Enrollee External Appeal Process

If you disagree with a decision made by your HMO about paying a claim, a prior authorization, or other health care services that were not covered as you expected, you can take the following steps: 

1. Health Maintenance Organization internal appeal - The first step in the Appeals process is to file an internal appeal with your HMO. An enrollee or their representative can start the appeals process with phone call or written communication to the HMO’s Member Services Department. The appeal process is provided at no cost to enrollees.
2. Minnesota Department of Health external appeal - Enrollees have the right to file an appeal with their HMO and with the Minnesota Department of Health (MDH). If the internal appeal was denied, you have the right to contact the Department of Health to file an external appeal. The State of Minnesota contracts with up to three independent third parties that can provide an appeal for HMO enrollees who are dissatisfied with the HMO’s appeal decision. To file an external appeal, complete the External Appeal form (PDF).  
3. Pursue legal action - If you are dissatisfied with the outcome of the External Appeal, you have the right to seek legal counsel or to have an attorney assist you in resolving the issue in court. 

External Appeals Frequently Asked Questions

What is an “adverse determination?”

This is a decision by a health plan company to deny a health care service you are requesting, such as a prior authorization, or a denied claim for services already provided.

Who can file an External Appeal through MDH?

Enrollees of HMOs are eligible to file an external appeal request through MDH. If you aren’t sure if you are enrolled in an HMO plan, you may contact your insurance company or MDH to see what type of plan you have.  

Do other departments handle external appeals?

Yes, if you have a Medicaid plan your external appeal is likely handled by the MN Department of Human Services (DHS); Medicare plans (including Advantage and Medicare Supplement plans) are handled by the U.S. Centers for Medicare and Medicaid Services (CMS); self-insured plans are handled by the U.S. Department of Labor; and some plans are handled by the MN Department of Commerce.  

How does a consumer request an external appeal?

To initiate the external appeal process, you, the enrollee, or anyone acting on behalf of the enrollee must complete an external appeal form. You may request an external appeal within six months of the date of the adverse determination. If you are enrolled in a Minnesota HMO, and unable to print the form from this page, you may request the external appeal form by phone, email or by submitting a written request to: 

Minnesota Department of Health 
Managed Care Systems Section 
P.O. Box 64975 
St. Paul, MN 55164-0975 
651-201-5100 or 1-800-657-3916 
Email: health.mcs@state.mn.us

What if I am disabled, non-English speaking, or require assistance?

You (the enrollee), your representative, your health care provider, or the HMO should contact MDH (see contact information above) if the enrollee is disabled, non-English speaking, or requires assistance to submit an external appeal request.

When can I expect an answer after requesting an external appeal?

A normal external appeal may take up to 45 days after the case is submitted to the independent review organization.

What if my case is urgent and needs to be reviewed quickly?

To make a request for an expedited external review, the enrollee or representative may make the request by phone to the Department of Health. If the time to use mail would unreasonably delay the expedited external review, alternative means of information exchange (such as fax or e-mail) may be used. See below for details about the expedited review process.

When is an external review available?

In most cases, you must first complete an appeal with your HMO before you can request an external appeal through MDH. Enrollees should check their summary of benefits, or Certificate of Coverage for their next step.

What if I can't wait the normal 45 days for external review?

If you believe a 45-day wait could harm your health, or the health of the person you are representing, you may request an expedited 72-hour appeal. It is important to have a health care provider fill out the “expedited” section of the External Appeal form if you need your answer within 72 hours.

Why does the Department of Health review the external review request?

MDH will screen each request for external review. The review will cover three elements:

1. Is the requestor enrolled in a fully insured plan issued by a Minnesota HMO?
2. Is it 6 months or less since the decision you are appealing?
3. Have you completed the first level of appeals with your HMO?

If all three criteria are met, then MDH will submit the external appeal for review, and will contact you with more information.

What if MDH determines my request is not appropriate for external appeal?

If your request is determined not eligible, MDH will contact you with other options.

1. If your review is ineligible because MDH does not regulate your health plan, MDH will let you know if there are other options for external appeal.
2. If it has been more than 6 months since the decision, MDH will review your appeal to determine if MDH can conduct an investigation. If this is the case, MDH may ask you to complete a complaint form.
3. If you have not completed the first level of appeal within your HMO, MDH will let you know so you can appeal the decision within your HMO.

How do I know if my case is appropriate for external appeal?

If the request for external appeal is not accepted, the Department of Health or the independent review organization will contact you (the enrollee) and the HMO within two business days of receipt of your request application.