*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: May 1, 2009 |
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Archived: June 1, 2016 (Previous Version) |
When Minnesota Health Care Programs clients are not satisfied with county or state agency decisions, they or their authorized representatives may request that the DHS State Appeals Office review the state or county agency actions or inactions.
These people may appeal any county or state action:
l Applicants.
l Clients.
l Former clients.
l Some people who have financial obligations to enrollees.
Providers do not have the right to appeal denied requests under the department's fair hearing process. Providers may appeal health plan denials of payment or services, with the client’s written permission.
Note: For information on continuing benefits during an appeal, see Continued Benefits.
Clients must receive written notice of their appeal rights whenever a state or county action affects their coverage under the Minnesota Health Care Programs. The written information must include:
l The right to appeal to the county agency, MinnesotaCare Operations, or directly to the DHS State Appeals Office for a fair hearing.
l How to file an appeal.
All DHS notices include the required information. For more information on notice content, see Notices.
Advise clients who wish to appeal that they must file appeal requests in writing by:
l Completing the Appeal to State Agency (DHS-0033). Offer the form to any client interested in appealing.
l Writing a letter. Consider any written and signed communication that requests a hearing to be an appeal request. The letter may, but is not required to, express disagreement with a county or state agency decision.
The request must state what action the client is appealing. Contact the client for clarification if necessary.
The client may send the appeal request to the county agency, tribal agency or MinnesotaCare Operations, or send it directly to the DHS State Appeals Office:
Minnesota Department of Human Services
Appeals Office
PO Box 64941
St. Paul, MN 55155-0941
Forward all appeal requests received at a county, tribal agency or MinnesotaCare to the DHS State Appeals Office, regardless of:
l when the appeal is received, and
l the issue the client wishes to appeal.
The DHS State Appeals Office determines whether the request is timely and whether the issue is appealable.
The DHS State Appeals Office forwards a copy to the county or to MinnesotaCare Operations if the client sends the appeal request directly to the State Appeals Office. The DHS State Appeals Office forwards a copy to the health plan if the appeal request concerns managed care service issues.
The DHS State Appeals Office sends information to clients about:
l The right to represent themselves or to have other people represent them at the hearings.
l The right to examine documents and records in the case file.
Reminder: Do not release information classified as confidential. See Clients' Privacy Rights.
l The right to question or refute any testimony or evidence given at the hearing.
l The right to submit evidence at the hearing to establish facts and circumstances in the case.
The client, the provider on behalf of the client, or the county managed care advocate may request an expedited state appeal hearing. Request an expedited appeal when failure to act could seriously threaten the client's:
l life,
l health,
l ability to attain, maintain, or regain maximum function.
Indicate Request Expedited Appeal at the top of the appeal form.
The State must take final action within three working days of receiving a request from the client that meets the criteria of an expedited appeal.
The health plan must take final action within 72 hours from receipt of the request from the client in these situations if the action is an appeal to the health plan.
Make the necessary arrangements if the client requests a telephone hearing.
To be considered timely, the client must request the appeal hearing within 30 days after receiving a notice of action, or within 90 days after receiving the notice, with good cause.
The client must show good cause for making a late request if the he or she submits the appeal request within 31-90 days after the notice. The appeals office determines good cause along with the other issues at the hearing.
Forward all appeal requests to the DHS State Appeals Office even if it appears that the request may be later than the 90-day timeline. The DHS State Appeals Office will set up a hearing and decide the issues of timeliness and good cause.
If the county, tribal agency or MinnesotaCare Operations receives an appeal request from the client or from the DHS State Appeals Office:
l Complete a summary of the issues and county or state agency actions leading to the appeal on the State Agency Appeal Summary (DHS-0035) or a memo. Include all information related to the appeal issues.
l Provide copies to the client and the DHS State Appeals Office before the hearing. Mail or otherwise deliver the appeal summary at least three working days before the date of the hearing.
l Schedule a time for a review of the case file if the client asks to review it. Make free copies of records in the case file for the client if requested. ”Case file” includes the information, documents and data, in any format that have been generated, collected, stored, or disseminated by the agency in connection with the person and the program or service involved.
The Appeal Hearings Information (DHS-2811) pamphlet explains details about the hearing for clients.
The DHS State Appeals Office schedules hearings at least five days after receiving the appeal notice filing. This allows time for proper notification. Hearings can be sooner if the client and the human services judge consent.
The human services judge may conduct a face-to-face hearing or a telephone hearing if the client agrees. County agencies must have equipment available to conduct hearings by telephone (such as a telephone speaker attachment). Hearings are private and not open to the public.
Evidence given at the hearing is the basis for the human services judge's recommendation and for the commissioner's decision. The client may give additional evidence at the hearing.
During the hearing, the human services judge collects information to determine:
l Timeliness of the appeal request.
l Whether the issue is appealable.
l Whether there is good cause for nonpayment, noncooperation or late payment.
l Whether the county, MinnesotaCare Operations, or state agency acted correctly.
Before the hearing, offer the client an opportunity to resolve the appealed issue informally. The client may request an agency conference including a supervisor or the agency director. The conference may be a phone conference or a face-to-face conference.
Do not require a client to try to resolve an issue at the local level before filing an appeal with the DHS State Appeal Office. The client may file a state appeal hearing request without a local conference discussion.
Do not delay sending the appeal request to the DHS State Appeals Office while resolving issues locally.
Ask the client to sign a written request to withdraw the appeal if a conference or other informal means resolves the appeal. Send the withdrawal request to the DHS State Appeals Office.