Enrollee External Appeals and Complaints
Complaint Process
If you are unhappy with a decision made by your Health Maintenance Organization (HMO), or how you were treated by your HMO, you can file a complaint with the Minnesota Department of Health (MDH). The decision from your HMO can be related to your HMO not covering services you think should be covered, not paying claims you think should be paid, or if you think you were asked to pay more than you should. You can also file a complaint if you believe your access to providers is limited, or if you are not happy with how you have been treated or served.
HMO complaints can happen at the same time as an internal complaint or appeal with the HMO.
HMO Complaints Options
- Health Maintenance Organization internal complaint - Minnesota law requires each HMO to establish an internal process whereby enrollees can complain about any action taken by their 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 complaint process is provided at no cost to enrollees.
- Minnesota Department of Health complaint - HMO enrollees have the right to file complaints with MDH. An enrollee or their representative can start the complaint process with a phone call or downloading and completing the HMO Complaint Form (PDF) electronically, which you may email or mail to MDH. MDH can investigate to determine if the HMO and its providers have acted consistent with applicable law and with the terms of the enrollee's health plan. There is no cost to file a complaint with the Minnesota Department of Health.
- Pursue legal action - You always have the right to seek legal counsel or to have an attorney assist you in pursuing your complaint and appeal options. However, once litigation has begun, the Department of Health can no longer investigate your complaint.
Other Types of Complaints
Balance Billing or Surprise Bills complaints
You may have heard stories from friends or in the news about balance bills or surprise bills from health care providers. Starting in 2022, a new federal law, The No Surprises Act, will protect you from many types of surprise bills. To learn more about the law and how to file a complaint about balance billing, visit The No Surprises Act: New Protections from Surprise Billing.
Quality of Care Complaints
The Minnesota Department of Health reviews complaints about quality of care by your health plan or its contracted medical providers. Quality of care issues may involve concerns about a provider's knowledge or skill, behavior, attitude, diagnosis, and treatment. Quality of Care complaints use the same HMO Complaint Form (PDF) as HMO complaints. To learn more about Quality of Care complaints, visit Quality of Care Complaints.
Frequently Asked Questions about HMO Complaints
Who can file a complaint?
Enrollees of HMOs can file a complaint with MDH. Additionally, MDH accepts complaints from any insurance enrollees if their complaint is regarding Quality of Care or the No Surprises Act.
What happens when I file a complaint with MDH?
MDH will review your complaint to determine if more information is needed. Once they make this determination, MDH will open an investigation, and request information from you or your representative, your HMO, and/or your provider.
How long will the investigation take?
A normal complaint investigation may take up to 45 days, depending on the nature and complexity of the complaint. Your investigator will contact you if there is a delay or additional information is needed.
Are the results of the investigation binding?
No, the results of the investigation are not binding, and if the findings are not in your favor you may have other options, including pursuing an external appeal.
Are there other state agencies that may be able to help me?
Yes, there are other agencies within the State of Minnesota that may be able to help with your complaint, such as the Attorney General's Office Consumer Assistance Request Form, or the Office of Health Facility Complaints, What the Office of Health Facility Complaints Can Investigate.