Effective: December 1, 2006
27.05.05ar1 - Managed Care Appeals (Archive)
Archived: May 1, 2009
Enrollees who receive services through managed care plans can appeal issues related to managed care enrollment and benefits directly to the state appeals office. They also have several other levels of contacts to resolve medical service and payment issues. Enrollees are not required to contact any of these other resources before filing an appeal.
Detailed instructions for health plans, county advocates and ombudsmen are included in the Prepaid Minnesota Health Care Programs Manual.
Managed Care Appeal Issues.
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Each health plan contracting with DHS must have procedures for handling enrollee complaints.
Health plans must give each enrollee a Certificate of Coverage. This certificate includes the health plan grievance and appeal procedures.
An enrollee who disagrees with a health plan resolution or any health plan action may file an appeal directly with the State Appeals Office.
Each managed care county has designated advocates. MA and GAMC enrollees may contact the county managed care advocates for help in resolving health plan issues. MinnesotaCare enrollees whose cases are serviced by the county agency may also contact the county managed care advocate.
County advocates may be able to resolve problems with health plans or help enrollees file appeals. County advocates do not approve requests for change in health plans because of inaccessibility. The Ombudsman reviews and acts on these requests.
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MinnesotaCare enrollees whose cases are serviced by DHS may direct complaints or problems to the DHS Managed Care Ombudsman. County managed care enrollees may also contact the Ombudsman instead of or in addition to the county managed care advocate.
An ombudsman is a neutral investigator and problem solver. The DHS Managed Care Ombudsman:
l Helps clients enrolled in health plans with access, service, and billing problems.
l Provides information about the managed health care grievance and appeal processes that are available through the health plan and the state.
l Reviews requests for changing health plans because of inaccessibility of services or providers. All enrollees must request health plan changes through the Ombudsman. The county managed care advocates do not approve these requests.
Note: Enrollees should contact the health plan to request a change in primary care providers within the same health plan. They do not need to contact the Ombudsman.
Workers should contact the DHS enrollment coordinator when an agency error resulted in an incorrect health plan or primary care physician or dentist choice.
Enrollees may contact the Ombudsman by:
l Sending a letter to:
Ombudsman for State Managed Health Care Programs,
PO Box 64249,
St. Paul, MN 55164-0249.
l Calling any of these numbers:
l Sending a fax to 651-431-7472.
For more information, visit the web site: Office of Ombudsman for State Managed Health Care.
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Managed Care Appeal Issues
Managed care clients may appeal the following issues to the State Appeals Office:
l Mandatory participation in MA managed care. Pending the state appeal decision, the client must either select or be assigned a plan.
Note: There is no provision for appealing mandatory participation in MinnesotaCare or GAMC managed care.
l Denial, termination, or reduction of services by the health plan.
l Payment of bills for services already provided.
l The health plan's resolution of a grievance or appeal.
l Whether travel time to the primary care provider is excessive. In the Twin Cities metropolitan area, travel time over 30 minutes from the client's residence is excessive. In the rest of the state, travel time is excessive by community standards.
l Request to change health plans when travel time is less than 30 minutes, but the client considers the travel time excessive.
l Request to change health plans for good cause issues, including:
n Poor quality of care.
n Lack of access to providers experienced in dealing with the client's health care needs.
n Continuity of care (Counties may contact their DHS enrollment coordinators first.).
n The county entered the wrong health plan or primary care provider.
n Other reasons satisfactory to the State agency.
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