When you enroll in a HealthPartners Medicare or HealthPartners MSHO plan, you expect the best. And that’s what we’re committed to providing you.

If you’re unhappy with your coverage or have concerns about the quality of your care, you have the right to request an initial determination, appeal the outcome of a coverage decision or file a grievance. If you take any of these actions, we will not penalize you in any way or disenroll you from your plan. We handle all complaints fairly.

Initial determinations, appeals and grievances explained

If you’re unsatisfied with some aspect of your coverage or need to make a request, these processes are the best way to tell us what’s going on.

Initial determinations

An initial determination is a decision we make about your benefits, coverage or the amount we will pay for your medical services or medicine. Initial determinations are also called organization determinations or coverage determinations.

Appeals

An appeal (or request for reconsideration) is a formal way of asking us to review information and change an initial determination we already made.

Grievances

A grievance is any complaint that does not involve a determination, including concerns about the quality or timeliness of the care you received.

We’re here to help

If you have questions, need help with the process or want to follow up on an open complaint, contact Member Services. Our Member Services team can also tell you the total number of grievances, appeals and exceptions we’ve received.

Detailed instructions for requesting an initial determination or filing an appeal or grievance are below.

Requesting an initial determination

You may ask us to make a decision about your benefits, coverage or the amount paid out for your medical services or medicine. Initial determinations may also be called organization determinations or coverage determinations.

First, send us your request in the way that’s easiest for you. You, your doctor or your legal representative can send your request.

Send a request via phone

From Oct. 1 through March 31, we’re available 8 a.m. to 8 p.m. CT, seven days a week. From April 1 through Sept. 30, we're available 8 a.m. to 8 p.m. CT, Monday - Friday.

Send a request via fax

Our fax number is 952-883-7333.

Send a request via mail

HealthPartners Member Services
MS 21103R
P.O. Box 9463
Minneapolis, MN 55440-9463

Make a request in person

HealthPartners
Member Services
8170 33rd Ave. South
Bloomington, MN 55425

Responses to determination requests

After we receive your request, we’ll review it and respond. We provide most responses within 14 days of getting the request. If it’s in your best interest, we may take longer. We’ll let you know if we need more time.

  • If we say yes, we’ll approve the agreed-upon coverage within 14 days of getting your request. If we need more time to make our decision, you’ll have coverage by the end of our extended period.
  • If we say no, we’ll send you a written statement explaining our decision. We’ll also include information regarding your appeal rights.

If waiting the standard review time will seriously jeopardize your life or health, we’ll respond within 72 hours.

You, your doctor or your legal representative can request coverage for your medicine by completing this Request for Medicare Prescription Drug Coverage Determination form (PDF), or ask your doctor to fill out this Prior Authorization form (PDF).

Send completed forms to us in the way that’s easiest for you.

Send a request via fax

Our fax number is 952-853-8700 or 888-883-5434

Send a request via mail

HealthPartners Pharmacy Administration Department
P.O. Box 1309
Mail Stop: 21111B
Minneapolis, MN 55440-1309

Find the request form online
  1. Sign in to your online account.
  2. Select “Find a form.”
  3. Go to the “Medicare” section and find “Request for Medicare prescription drug coverage determination” Then select “Fill out online.”
Responses to determination requests

After we receive your request, we’ll review it and respond. If you requested a determination about a drug you haven’t received, or if you’re requesting an exception, we’ll respond within 72 hours. If you requested a determination about a payment for a drug you already bought, we’ll respond within 14 calendar days.

If waiting for the standard review time will seriously jeopardize your life or health, we’ll respond within 24 hours.

Requesting an appeal

If you disagree with our initial determination, you can file an appeal. Appeals are reviewed by someone who wasn’t involved in the initial determination to ensure your request is given an unbiased review.

There are five levels in the appeals process.

You have 60 calendar days from the date of an initial determination to make an appeal. We may extend this deadline if you have a good reason for needing more time.

Make your appeal in writing. Fill out the appropriate form for the kind of plan you have:

You can also request a redetermination of a Medicare Prescription Drug Denial (PDF).

Send the completed form to us in the way that’s easiest for you.

Send an appeal via fax

Our fax number is 952-853-8742.

Send an appeal via mail

HealthPartners Member Rights & Benefits
MS 21103R
P.O. Box 9463
Minneapolis, MN 55440-9463

Responses to medical appeals

If you haven’t received care yet, you’ll get a written response to your appeal within 30 days. If you’ve already received the care, you’ll get a response within 60 days (30 days for MSHO plans).

If your appeal is for a Medicare Part B prescription drug, you’ll get a written response within seven calendar days.

If waiting the standard review time will seriously jeopardize your life or health, we'll respond within 72 hours.

Responses to prescription drug appeals

If you haven’t received the prescription drug yet, you’ll get a written response within seven days. If you've already purchased the prescription drug and are requesting reimbursement, you'll get a written response within 14 days.

If waiting the standard review time will seriously jeopardize your life or health, we’ll respond within 72 hours.

Medical appeals

If we deny your appeal, we automatically send your case to an independent review organization. That organization is not part of HealthPartners. The independent review organization will send you their decision for your appeal.

If you have MSHO, your case is sent to an independent review organization only if the appeal is about Medicare-covered benefits. For Medicaid-covered services, you may:

  • Request a State Appeal (Medicaid Fair Hearing with the State)
  • Call the Managed Care Ombudsman at 651-431-2660 or toll free at 1-800-657-3729 (outside the Twin Cities metro area) for help filing a State Appeal (Medicaid Fair Hearing with the State)
  • Call the Minnesota Department of Health at 651-201-5000 or toll free at 1-888-345-0823 (outside the Twin Cities metro area)
Prescription drug appeals

If we deny your appeal, you can request a reconsideration from an independent review organization. That organization is not part of HealthPartners. We will explain how to request a reconsideration in our appeal decision letter to you.

If the independent review organization from level 2 doesn’t rule in your favor, you can ask for a review by an Administrative Law Judge (also called an ALJ/attorney adjudicator). You must make this request within 60 days of the decision by the independent review organization.

In order for an ALJ/attorney adjudicator to review your appeal, the coverage must be greater than a specified amount. If it’s not, you can’t appeal any further.

If you’re not satisfied with the ALJ/attorney adjudicator’s decision in level 3, you can ask to have your case reviewed by the Medicare Appeals Council. You must file your request within 60 calendar days of the date of receipt of the written ALJ/attorney adjudicator decision or dismissal. The Medicare Appeals Council will decide whether to review your case. They don’t review every case.

If the contested amount is above a specified dollar amount and the Medicare Appeals Council denied your request for review, you can appeal to federal court. To appeal, you need to file a civil action in a U.S. district court. The letter you receive from the Medicare Appeals Council (in level 4) will tell you how to request this review.

Filing a grievance

If you’re unsatisfied with an aspect of your plan that doesn’t involve coverage, such as quality or timeliness of care or service, you can file a grievance.

You have 60 days from the date of care to file a grievance. However, if you have MSHO, there’s no time limit for filing a grievance.

Send us your grievance in the way that’s easiest for you.

File a grievance via phone

Please call Member Services.

We resolve most verbal complaints the same day we receive them. However, if you communicate your complaint verbally and we do not resolve it to your satisfaction within a required time frame, we’ll give you additional options, including filing a written complaint.

File a grievance via mail or fax

Fill out the appropriate complaint form for the kind of plan you have:

Mail completed forms to:

HealthPartners Member Rights & Benefits
MS 21103R
P.O. Box 9463
Minneapolis, MN 55440-9463

You can also fax completed forms to 952-853-8742.

Responses to grievances

After we receive your complaint, we’ll review it and respond. Our Member Rights & Benefits team will notify you within 10 days that we received your complaint.

We’ll send our response within 30 days of receiving your complaint form. If it’s in your best interest, we may take an additional 14 days to respond to your concerns. We’ll let you know if we need an extension.

Have someone else submit an initial determination, appeal or grievance

If you appoint someone as your representative, they can request an initial determination, request an appeal or file a grievance on your behalf. You can appoint anyone to act as your representative, such as a relative, friend, advocate, attorney, physician or someone else you trust.

To appoint a representative, fill out the Appoint a Representative form (PDF) from the Centers for Medicare & Medicaid Services. Then fax it to us at 952-853-8742 or mail it to us at:

HealthPartners Member Rights & Benefits
P.O. Box 9463
Minneapolis, MN 55440-9463

Legal information

Last updated October 2021

H2422_001601 Approved 10/1/2021
H2462 H4882_001601 Accepted