Whom to contact:

Minnesota Department of Commerce or Department of Health

Who can appeal:

You, your provider (with consent), or your authorized representative

What you can appeal:

Denials of coverage for services the health plan determines are not medically necessary or are experimental or investigational. You can also appeal grievances related to contract disputes or other services.

When you can appeal:

You must file after the dispute has been appealed through the one level of the health plan’s internal process and you have received an adverse determination.

What to send:

• A completed Request for External Review, which includes a medical records release.
• $25 check.
• Any supporting information for your case.

What you must pay:

$25 (may be waived in cases of hardship)

What will happen:

• The Department of Commerce or the Department of Health will evaluate your case for eligibility.
• Your case will be sent to an independent review organization
• If your case does not involve a medical determination, you may request mediation, which involves a hearing by telephone or in person.  Both you and your health plan must agree to mediate the dispute for this option to be used.
• If no agreement is reached, your case will be returned to the review organization.
• You, your provider, and your health plan will be notified within 3 days after the review organization receives the case.
• You, your provider and your health plan may submit pertinent information to the review organization within 10 days after notification.
• The review organization will evaluate your case and make a decision.

When you will get a decision:

Within 40 days after the case is submitted to the independent review organization.

In urgent situations:

For medical determinations for services that have not been received or are ongoing, if your provider believes an expedited review is necessary, a decision will be made within 72 hours.