HMO Enrollee External Appeals and Complaints
Appeal Process

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.

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.  

Yes, if you have a Medicaid plan your external appeal is called a state fair hearing, and 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. 

To initiate the external appeal process, you, the enrollee, or anyone acting on behalf of the enrollee must complete the external appeal request either on MDH's portal or complete an  External Appeal form (PDF). 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 

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.

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

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. You may request an expedited appeal when you complete the request on our portal or on the PDF form. Please note, you will need the contact information of your provider to request an expedited appeal.  

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.

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.

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.

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. 

The result of an External Appeal is nonbinding on you, the insured, but it is binding on the health plan company. If you disagree with the outcome of your external appeal, you have the right to appeal the decision in court through your own legal action. If the health plan company loses, it cannot appeal the decision.