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Medicare appeals and grievances processes

When you enroll in a HealthPartners UnityPoint Health plan, you expect the best. And that’s what we’re committed to providing you. If you want us to review your request for coverage, or if you have concerns about the quality or timeliness of your care, we want to know.

If you make a complaint, we’ll be fair in how we handle it. You won’t be disenrolled from your plan or penalized in any way.

 

What’s the difference between a Medicare coverage decision, a Medicare appeal and a Medicare grievance?

    • A coverage decision is a decision we make about your benefits, coverage or the amount we will pay for your medical services or medicine. (You may also hear this referred to as an organization determination.) If you disagree with a coverage decision, you can appeal our decision.
    • An appeal is a formal way of asking us to review information and change our decision. You can ask for an appeal if you want us to change a coverage decision we already made.
    • A grievance is any complaint other than one that involves a coverage decision. Grievances may include concerns about the quality or timeliness of the care you received.

How it all comes together:

  1. Our first decision about the medical care you want is called a coverage decision.
  2. If you disagree with the decision we make, you can appeal the decision. This is also called requesting a reconsideration.
  3. If you’re unhappy with the quality of the care we provided, you can file a grievance.

 

Can someone else file an appeal or grievance for me?

Yes. A representative can file an appeal or grievance on your behalf. You can appoint anyone to act as your representative. Your representative could be a relative, friend, advocate, attorney, physician or someone else you trust.

Read more about appointing a representative. Fill out this form from the Centers for Medicare and Medicaid Services site and send it to us.

How do I make a request?

On this page, you can find instructions for requesting coverage, filing an appeal or filing a grievance:

Curious about the total number of grievances, appeals and exceptions we’ve received? Contact Member Services for the numbers.

How do I request a Medicare coverage decision?

A coverage decision is a decision we make about your benefits, coverage or the amount we’ll pay for your medical services or medicine. This decision is also called an organization determination when it is about a medical decision. It is called a coverage determination when it relates to a prescription drug request.

 

Requesting coverage for medical care

Step 1:

Send us your request. You, your doctor or your representative can do this. You can send your request in whatever way is easiest for you – phone, TTY, fax or mail.

By toll-free phone:

888-360-0544

TTY: 771

By toll-free fax:

952-883-7333

By mail:

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

Please call Member Services if you need help with requesting a coverage decision. Call us toll-free at 888-360-0544, TTY 711.

Step 2:

We’ll review your request and give you an answer. We provide most responses within 14 days of getting the request. If it’s in your best interest, we may take more time to review your request. However, we’ll let you know if we need more time.

    • If we say yes to your request, 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 to your request, we’ll send you a written statement that explains our decision. We’ll also include your appeal rights.

If you need a fast response and waiting for the standard review time will seriously jeopardize your life or health, we’ll respond within 72 hours.

Requesting coverage for prescription drugs (Part D)

Step 1

You, your doctor or your representative can request coverage for your medicine. You can make your request by phone, in writing or by fax. Complete this Request for Medicare Prescription Drug Coverage Determination form, or ask your doctor to fill out this Prior Authorization form.

Send the completed form to us:

By fax:

888-883-5434

By mail:

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

Online:

    • Log on to your HealthPartners account
    • In the “My plan” tab, click “Grant authorization or submit requests with our forms
    • “Request for Medicare prescription drug coverage determination” to begin

Step 2

We’ll review your request and give you an answer.

If you requested a decision about a drug you haven’t received or if you’re requesting an exception, we’ll give you an answer within 72 hours. If you requested a coverage decision about a payment for a drug you already bought, we’ll give an answer within 14 calendar days.

If you need a fast response and waiting for the standard review time will seriously jeopardize your life or health, we’ll respond within 24 hours.

Questions about requesting a coverage decision?

If you have questions, or if you would like someone to talk you through the process, please contact Member Services.

 

How do I file a Medicare appeal?

An appeal is a formal way of asking us to review information and change our decision. If we said no to your original request, you can ask us to look at it again.

Your appeal will be reviewed by someone who wasn’t involved in the coverage decision. This helps make sure your request is reviewed with a fresh perspective.

Five appeal levels

Level 1:

You must make your appeal within 60 calendar days of our original decision. We may extend this time if you have a good reason for being late.

Initiate your standard appeal in writing by filling out the complaint form, or by requesting a redetermination for a Medicare Prescription Drug Denial.

Send the completed form to us:

By fax:

952-853-8742

By mail:

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

Please call Member Services if you need help with your appeal. Call us toll-free at 888-360-0544, TTY 711.

How long will it take to receive a response to my appeal?

For a medical appeal, if you haven’t received care yet, you’ll get a written response to your appeal within 30 days (if your appeal is for a Medicare Part B prescription drug, you will get a written response within 7 calendar days).

If you need a fast response and waiting the standard review time will seriously jeopardize your life or health, we will respond within 72 hours.

If you’ve already received the care, you’ll get a response within 60 days.

For a prescription drug appeal, if you haven't received the prescription drug yet, you’ll get a written response within 7 days.

If you need a fast response and waiting the standard review time will seriously jeopardize your life or health, we will respond within 72 hours.

If you've already purchased the prescription drug and are requesting reimbursement, you'll get a written response within 14 days.

Level 2:

For a medical appeal, if we deny your appeal, your case is automatically sent to an independent review organization. That organization is not part of HealthPartners or HealthPartners UnityPoint Health.

For a prescription drug appeal, if we deny your appeal, you can request a reconsideration from an independent review organization. That organization is not part of HealthPartners or HealthPartners UnityPoint Health.

Level 3:

If the independent review organization doesn’t rule in your favor, you can ask for a review by an Administrative Law Judge (also called an ALJ/attorney adjudicator). This request must happen within 60 days after 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 is not, you can’t appeal any further.

Level 4:

If you’re not satisfied with the ALJ/attorney adjudicator’s decision, you can ask to have your case reviewed by the 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 Council will decide whether to review your case. They don’t review every case.

Level 5:

If the contested amount is above a specified dollar amount and the 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 Council (in level 4) will tell you how to request this review.

Questions about filing an appeal?

If you have questions about your appeal, please contact Member Services.

 

How do I file a Medicare grievance?

A grievance is a complaint other than one that involves a coverage decision. A grievance may include a concern about the quality or timeliness of the care you received.

You have 60 days (from the date of care) to file a grievance. You can call us or send your complaint in writing. If you would like, we can help you fill out the form. Then, we would send it to you for your signature.

We’ll make every effort to resolve your complaint. We resolve the majority of oral complaints the same day they are received. If your grievance is not resolved to your satisfaction, we’ll review your complaint again.

Sending us your grievance

By phone:

Call Member Services.

By fax:

952-853-8742

By mail:

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

Our Member Rights & Benefits team will review your complaint. We’ll notify you within 10 days that we received your complaint. Within 30 days of receiving your complaint form, we’ll send you our response.

If it is in your best interest, we may take an additional 14 days to respond to your concerns. We will let you know if an extension is necessary.

Questions about filing a grievance?

If you have questions about your grievance, please contact Member Services.

Legal information

Last updated October 2020

H3416_000403 Accepted

 

Last updated October 2020

H3416_000403 Accepted

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