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 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.
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, or directly to the State Appeals Office for a fair hearing.
l How to file an appeal.
All DHS notices include the required information. The Minnesota Health Care Programs Application (HCAPP) (DHS-3417), Combined Application Form (CAF) (DHS-5223), and Health Care Renewal (DHS-3418) forms also include appeals information.
Advise clients who wish to appeal that they must file appeal requests in writing by one of these methods:
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 to be an appeal request, if it expresses disagreement with a county or state agency decision.
The request should state what action the client is appealing.
The client may send the appeal request directly to the state appeals office. Forward all requests received at the county or MinnesotaCare to:
State Appeals Office
Department of Human Services
444 Lafayette Road
St. Paul, Minnesota 55155-0941
Forward appeal requests, regardless of when they are received and the issue the client wishes to appeal. The Appeals Office determines whether the issue is appealable and whether the request is timely.
If the client sends the appeal request directly to the state office, the Appeals Office forwards a copy to the county or to MinnesotaCare. If there are managed care service issues, the Appeals Office forwards a copy to the health plan.
The 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 recipient, the provider on behalf of the recipient, 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.
If the action is an appeal to the health plan, the health plan must take final action within 72 hours from receipt of the request from the client in these situations.
If the client requests a telephone hearing, make the necessary arrangements.
To be considered timely, the client must request the appeal hearing within 30 days of receiving a notice of proposed action.
For continued benefits, the client must get the appeal request to the local agency or DHS by the later of these dates:
l Before the effective date of the action.
l Within 10 days after the notice mailing date.
If the client submits the appeal request within 31-90 days after the notice, the client must show good cause for making a late request. The appeals office determines good cause along with the other issues at the hearing.
Forward all appeal requests to the State Appeals Office even if the client submits the request after the 90-day timeline. The Appeals Office will set up a hearing and decide the issues of timeliness and good cause.
If the county or MinnesotaCare receives an appeal request from the client or from the Appeals Office:
l Complete a summary of the issues (including timeliness 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 Appeals Office before the hearing.
l If the client requests to review the case file, schedule a time for the case file review. Make free copies of records in the case file.
The Appeal Hearings Information (DHS-2811) pamphlet explains details about the hearing for clients.
The 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.
Examples:
n Nonpayment.
n Non-cooperation.
n Late payment.
l Whether the county, MinnesotaCare, 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 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 Appeals Office while resolving issues locally.
If you resolve the issue through a conference or other informal means, ask the client to sign a written request to withdraw the appeal. Send the withdrawal request to the State Appeals Office.