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Medica Administrative Manual > Provider Responsibilities > Complaint Review Process

Complaint Review Process

The Minnesota Department of Health requires clinics located in the state of Minnesota to report to each health plan any written and verbal quality of care complaints the clinic has received from that health plan’s enrollees. Written complaint reports must be submitted quarterly and show all complaints investigated and resolved in the reporting period, or indicate that no complaints were received. The clinic must submit reports by the 15th of the month following the end of each quarter.

Participating providers must comply with the Medica member complaint resolution process, as required by state and federal laws governing HMOs and insurance companies (see Minn. Stat. §62D.123, Subd. 2). Because the member complaint resolution process varies by Medica product and entity, participating providers may call the Medica Provider Service Center at 1 (800) 458-5512 for information about member complaint resolution processes.

Clinic Complaint Reporting Definitions (PDF)
Quality Complaint Reporting form (PDF)

Quality of Care Complaints

The Medica Quality Review Oversight Committee (QROC), an internal peer review body, directs and oversees the quality of care complaint program. The Quality Improvement department investigates quality of care complaints involving clinical or service quality. Qualified staff evaluates each complaint and may request provider input or medical records to validate the allegations. If a request for provider input or medical records is made, providers are required to respond in a timely manner and in accordance with the Medica medical record request policy. Medica will notify the provider in writing when the investigation is complete.

If the allegations are substantiated, next steps may include, but are not limited to:

  • Case closure and tracking to monitor possible trends
  • Request for corrective action plan from the provider
  • Referral to the Credentialing Subcommittee, Special Investigations Unit, or Legal department for further action

Unsubstantiated allegations are closed and tracked for possible trends.

The QROC and the Credentialing Subcommittee are regarded as peer review organizations (PRO) under state law. Any communication regarding cases is not subject to subpoena or discovery in any civil action. At the time of the complaint, the member receives an acknowledgement letter (for written, not verbal complaints) but is never informed of the determination as outlined in the legal requirements relating to the peer review process.

The QROC Committee and the Credentialing Subcommittee do not make benefit determinations or decisions on reimbursement issues.


Complaint and Appeal Procedure

When members have a complaint or disagree with how their plan is administered, they can contact Customer Service to discuss their options. Members can file complaints and request a review of the initial decision. Members have a minimum of one level of review internally and may have external appeal options as well. Some complaints and appeal need to be requested in writing or over the phone. Please refer members to the Customer Service phone number on the back of their identification card to discuss the process for their plan. Medica also has a process in place for resolving expedited appeals.

Members have the right to designate a representative to act on their behalf during the appeal resolution process. A provider may initiate an appeal on behalf of a member with a member’s written permission. Members must sign a Release of Information form acknowledging that the representative has their permission to review confidential information pertinent to their appeal.

Providers may contact the Clinical Appeals Department directly to initiate an appeal request on behalf of a member, except for members covered under Medica’s Medicare products. Any new information about a previously denied service will assist in an accurate and appropriate benefit determination. Written requests for appeal initiation should be directed to:

For Medica members with group/policy #IFB, send appeals to:

Medica
Clinical Appeals Department
Mail Route CW295
PO Box 9310
Minneapolis, MN 55440-9310
Fax Number 952-992-2836
Phone number 1-855-235-0511
For all other Medica members, send appeals to:

Medica
Clinical Appeals Department
Mail Route CP420
PO Box 9310
Minneapolis, MN 55440-9310
Fax: 952-992-8403
Phone number 1-800-458-5512

Issues regarding coding or reimbursement need to be directed to the Provider Service Center at 1-800-458-5512.



REV 6/2021

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