Complaints and appeals

Registering a complaint:

• You may register a complaint by calling Member Services at the number listed on your member ID card.
• If we cannot resolve your complaint through a telephone call, we will promptly provide you with an appeal form to complete and return to Member Services.
• Upon request, Member Services will provide assistance in submitting an appeal.

Appealing denials based on contractual coverage exclusions/limitations or for any services that you have already received:

• If HealthPartners denies a claim for these health care services and you want to appeal, you must notify Member Services in writing.
• Provide any additional issues, comments and documents you feel need to be considered in making a final decision.
• We will investigate your appeal and notify you in writing of HealthPartners’ first-level appeal decision within 30 days of receipt of your appeal request.
• If we are unable to resolve your issue within 30 days due to circumstances beyond our control, we will notify you that we may need up to an additional 14 days.

If the decision on your appeal is unfavorable and you wish to appeal further:

• You have the option of either a written reconsideration, telephone conference or a hearing before the Member Appeals Committee of the Board of Directors.
• If your request is denied by the Member Appeals Committee, you also have the right to obtain external review of our decisions. Member Services can assist you in initiating an external review.

Requesting an expedited appeal:

• If the plan denied coverage for urgently needed services based on our medical necessity criteria, you may request an expedited appeal.
• You may submit an expedited appeal in writing, or by calling our Medical Appeals Line at 800-331-8643.
• Within 72 hours, we will notify you of the plan’s decision.
• If you disagree with our decision, you have the right to seek an external review. Member Services will give you information on how to start this process.

For all appeals:

• If you have questions about a claim that was denied based on our clinical necessity criteria, you may request to speak with the reviewer involved in making the decision. Call our toll-free Medical Appeals Line at 800-331-8643. The line is staffed from 8 a.m.–5 p.m. CST on regular business days. After hours, leave a message and we will return your call the next business day.
• If all required reviews of your claim have been completed and your claim has not been approved, most members have the right to bring a civil action under section 502(a) of the Employee Retirement Income Security Act of 1974. This right does not apply to members of individual or conversion plans.
• Please read your membership contract for more information on your appeal rights. If you have questions, call Member Services.
• This health care plan may not cover all your health care expenses. Read your contract carefully to determine which expenses are covered and at what benefit level.