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Submit an Appeal

For Minnesota Health Care Programs Members


Which Medica plan do you have?

This form is only for the two plans listed above. Please call the number on the back of your Medica ID card to learn how to initiate an appeal.

Member Information

Do you require an interpreter?
Would you like to designate someone other than the member to serve as an authorized representative for this appeal?

Authorized Representative

If you would like to designate someone other than the member to serve as authorized representative, please fill out this section.

Reason for Appeal

Are your current benefits being stopped or reduced?

If you file an appeal within 10 days of Medica denying, terminating or reducing services, your benefits may continue if you elect to keep getting benefits. If you lose your appeal, the benefits you received during the appeal will be considered overpayments. Most of the time you have to pay back overpayments.

Do you want to KEEP getting benefits until the appeal decision or STOP getting benefits until the appeal decision?

Attestation

I attest that:

Last updated December 2022

H2458_1004798 Approved

Y0088_1004798_C