If you have concerns about your coverage or the care you’ve received, you have the right to file a complaint or to appeal the outcome of a coverage decision. We handle all complaints and appeals according to state and federal guidelines.
A complaint is any grievance you have about your HealthPartners insurance. Examples of complaints include concerns about your care or coverage, the service you received or the timeliness of the service.
An appeal is a formal request to review information and ask for a change in a decision we’ve made about your coverage.
Keep in mind that your HealthPartners insurance may not cover all your health care expenses. Please read your membership contract carefully to determine which expenses are covered and at what benefit level – some services may require prior authorization as part of our coverage criteria policies. Please also refer to your contract for more information on your appeal rights. The easiest way to access your plan documents is through your online account, but you can also look up your membership contract without signing in.
If you do choose to file an appeal, you’ll receive a full and fair review. For example, if you’re disputing a decision made by a medical director, doctor or other staff person, a different doctor or staff person will review your request to help ensure an unbiased review.
The complaint process depends on what kind of HealthPartners plan you have:
- If you have a Medicare plan with us, get more information about Medicare determinations, appeals and grievances.
- If you have a Medical Assistance (Medicaid) plan with us, call 866-885-8880 (TTY 711) for more information.
- If you have any other plan with us, you can register a complaint by calling Member Services at the number on the back of your member ID card or 800-883-2177. If we can’t resolve your complaint over the phone, we’ll explain your options for submitting an appeal. After we receive your appeal request, we’ll follow up with you regarding the action we took.
The appeal process depends on what kind of HealthPartners plan you have:
To appeal a decision about care you’ve already received, you, your health care provider or your authorized representative can fill out the HealthPartners complaint/appeal form (PDF) and return it to us.
To appeal a denied authorization for future care, you, your health care provider or your authorized representative can fill out the HealthPartners complaint/appeal form (PDF) and return it to us, or call us at 800-331-8643. We’re available Monday through Friday, 8:30 a.m. to 4 p.m. CT.
If we denied coverage for urgently needed services based on our medical necessity criteria, you can request an expedited review by noting your expedited request on the appeal form or when you call us.
You, your health care provider or your authorized representative can make your appeal request.
An authorized representative is someone you appoint to act on your behalf during the appeal process. If you wish to appoint a representative, please also complete and send us the last page of the complaint/appeal form with your appeal. (Parents or guardians on the same policy as a minor younger than 18 years old may appeal for the minor without authorization.)
In most cases, you must send us your appeal request within 180 calendar days of our original decision. The original decision date is the date of a denial letter or the date of an explanation of benefits (EOB) statement, whichever comes first.
Please include all information that’s requested. This includes:
- What you’re requesting and why
- The best phone number to reach you during the day
- Your email address (if you’d like to get the outcome of your appeal via email)
- Any other information you’d like us to consider for your appeal, such as comments, documents or records that support your request
If we have questions or need additional information after you send us your appeal, we’ll let you know.
After you, your health care provider or your authorized representative has fully filled out the appeal form, you can send it (and any supporting information) in the way that’s easiest for you:
After we receive your appeal request, we’ll review it and respond.
Within 15 or 30 days (depending on your plan), you’ll get a letter via mail or email with our decision and explanation. If we can’t respond to you within the required timeframe due to circumstances beyond our control, we’ll let you know – in such cases, we may need four to 14 additional days.
If you requested an expedited review and waiting the standard review time would jeopardize your life or health, you’ll get a response within 72 hours.
If we can’t fully approve your appeal, we’ll provide information and directions regarding further appeal options available for your plan.
If all required reviews of your claim have been completed and your appeal still hasn’t 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.
Call Member Services at the number on the back of your member ID card or 800-883-2177.