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Appeals and Grievances

For Medica Choice CareSM MSC+ Members

Do you have a concern?

If you have a concern with your service or care, we encourage you to call Member Services first. We'll do everything we can to resolve your concern over the phone.

8 a.m. – 6 p.m. Monday – Thursday

9 a.m. – 6 p.m. Friday

What if your concern isn’t resolved?
If we can't resolve your concern over the phone, you may need to take additional steps. These next steps include:

  • Appeals – a request to Medica to reconsider their position on paying for a claim or requested service
  • Grievances – a complaint

Below, we'll walk you through how to complete these next steps. If you choose to file an appeal or grievance, it will not affect your eligibility for medical benefits.

Appeals

If a claim or requested service is denied, you will receive a notice of denial letter from Medica. This letter tells you about the decision we have made about a claim or requested service.

If you disagree with the denial, you must file an appeal with Medica within 60 days after the date of the notice of denial letter. We may extend this time if you have a good reason for being late.

There are three ways to file an appeal:

  • Online
  • In writing
  • By phone
How to File an Appeal with Medica
Your appeal must tell us why you disagree with our decision to deny a claim or requested service. If you need a decision quickly, you will need to state that in your appeal as well. We do offer fast appeals when medically necessary.

There is no cost to you for filing an appeal with Medica.

You may have a relative, friend, advocate, provider or lawyer help with your appeal. Anyone may appeal on your behalf with your written consent. You may present your evidence and facts about the case in person, in writing or by phone. Your health care provider may appeal a service authorization decision without your consent.

Online

We offer a convenient online form for submitting your appeal request.

In Writing

To submit a written appeal, download, fill out and return our appeal form by mail.

Medica State Public Programs
Mail Route CP540
P.O. Box 9310
Minneapolis, MN 55440

By Phone
To submit an appeal via phone, call Medica Member Services toll-free at

What if I Disagree with the Appeal Decision?
If you disagree with the decision on the appeal, you may then file a State Appeal (Fair Hearing with the state). You must first receive a decision from Medica on the appeal before filing a State Appeal (Fair Hearing with the state). Or, if Medica doesn't respond to your appeal within 30 days or ask for an extension, you don't need to wait for our decision to file a State Appeal (Fair Hearing with the state).

How to File a State Appeal (Fair Hearing with the state)

To request a State Appeal (Fair Hearing with the state), you must contact the Minnesota Department of Human Services Appeals Division within 120 days of Medica's appeal decision.

A State Appeal (Fair Hearing with the state) includes a meeting with a Human Services judge, Medica and you or your authorized representative. Your hearing will be held by telephone unless you ask for a face-to-face meeting.

A State Appeal (Fair Hearing with the state) must be submitted in writing by mail or fax, submitted online, or it can be filed in person at the Appeals Division. 

Minnesota Department of Human Services – Appeals Division

Mailing:
P.O. Box 64941
St. Paul, MN 55164

In person:
444 Lafayette Road North
St. Paul, MN 55155

Phone: 1-800-657-3510 (TTY: ) 711 
Fax: 651-431-7523

 

Questions about State Appeals?
Call the Minnesota Department of Human Services Appeals Division at 651-431-3600, toll-free at 1-800-657-3510, or visit their website.


Grievances

A grievance is a formal complaint. You may submit a grievance to us at any time. Grievances may include:

  • Quality of care
  • Failure to respect your rights
  • Customer service
  • Delay in appropriate treatment or referral
  • Not responding to appeals or grievances in required time frames.
  • Other concerns

Filing a grievance with Medica means that you would like us to address your complaint. This is not part of the appeals process; but you can submit a grievance along with an appeal and it will not affect the outcome of the appeal.

How to Submit a Grievance to Medica

There are three ways to submit a grievance to Medica:

  • Online
  • In writing
  • By phone

If your grievance is about our denial of an expedited appeal or a grievance about urgent health care issues, we will respond to you within 72 hours. Otherwise, we'll contact you in writing within 10 calendar days to let you know we've received your complaint.

How long it takes to respond to your grievance depends on how you submit it (see below), but we may extend the time frame by up to 14 calendar days if you request the extension or if we justify a need for additional information and the delay is in your best interest.

Online

We offer a convenient online form to submit your grievance.

In Writing
Once completed, mail your form to:

Medica State Public Programs
Mail Route CP540
P.O. Box 9310
Minneapolis, MN 55440

We respond to grievances submitted in writing within 30 days.

To submit a grievance in writing, download, fill out and return our paper form:

By Phone

To submit a grievance by phone, call our Member Services toll-free at

8 a.m. – 6 p.m. Monday – Thursday

9 a.m. – 6 p.m. Friday

We respond to grievances submitted by phone within 10 days.

How to Submit a Grievance to the State of Minnesota

If you disagree with our decision on your grievance, you can file your complaint with the Minnesota Department of Health (MDH).

In Writing
MDH Health Policy and Systems Compliance Monitoring Division Managed Care Systems
P.O Box 64882
St. Paul, MN 55164

By Phone
Call toll-free 1-800-657-3916 or 651-201-5100 (TTY: 711) .

Online
File a complaint online at the MDH website.

 

Ombudsman Office

You may also contact the Ombudsman for Public Managed Health Care Programs about your complaint. They can be reached at 651-431-2660 or 1-800-657-3729. TTY: 1-800-627-3529.

 

Legal Information About Appeals and Grievances

If you want a more detailed explanation of appeals and grievances, refer to your Member Handbook (PDF).

American Indians can continue to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral.


Last Updated: November 2021