How to file an appeal or grievance
If you have a concern regarding a grievance or an appeal related to your prescription drug coverage, please call Member Services.
HealthPartners® Freedom Plan (Cost) members please call: 952-883-7979 or 1-800-233-9645 from 8 a.m. to 6 p.m., Monday through Friday. TTY users should call 952-883-6060 or 1-800-443-0156.
HealthPartners® Classic Plan (HMO) members please call: 952-883-7676 or 1-866-233-8734 from 8 a.m. to 6 p.m., Monday through Friday. TTY users should call 952-883-6060 or 1-800-443-0156.
HealthPartners® Classic Minnesota Senior Health Options (MSHO) Plan (HMO) members please call: 952-967-7029 or 1-888-820-4285 from 8 a.m. to 6 p.m., Monday through Friday. TTY users should call 952-883-6060 or 1-800-443-0156.
You can mail your grievance or appeal request to:
HealthPartners
P.O. Box 9463
Minneapolis, MN 55440-9463
Or fax it to us at 952-883-7333.
If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from your HealthPartners plan or penalized in any way if you make a complaint.
What is a grievance?
A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with HealthPartners Prescription Drug Plan or one of our network pharmacies that does not relate to coverage for a prescription drug. Grievances include quality and timeliness issues.
How to file a grievance
Step 1:
You may submit a grievance to Member Services either in writing or orally, no later than 60 days after the event. Member Services will make every effort to resolve the grievance. If the oral grievance is not resolved to your satisfaction within 10 calendar days of receipt of the grievance, we’ll offer to provide a grievance form to you, which must be completed and returned to Member Services for further consideration. We’ll assist you in completing this form, or will complete the form and mail it to you for your signature, if you ask for assistance.
Step 2:
Member Services will investigate the grievance and provide for informal discussions, consultations, conferences or correspondence between you and a person with the authority to resolve or recommend resolution of the grievance. We’ll notify you within 10 business days that we received the written grievance. We’ll contact you in writing of our decision within 30 days of receipt of the written grievance or grievance form. We may take up to an additional 14 days to notify you of the decision if you request the extension or if we justify a need for additional information and the delay is in your best interest.
Step 3:
If you disagree with our initial decision, you may notify Member Services in writing. Member Services will provide you with the option of either a written reconsideration, or an oral reconsideration process before the Member Appeals Committee. The term “reconsideration,” as used in this Step 3, applies to any issue other than those listed under the reconsideration step of the Medicare Appeals Process.
What is a redetermination?
A redetermination is any of the procedures that deal with the review of an unfavorable coverage determination. You would file a redetermination if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we’ll pay for a prescription drug.
How to file a redetermination
Step 1:
You need to file your redetermination within 60 calendar days from the date included on the notice of our coverage determination. Please call us at the numbers shown listed above if you need help with filing your redetermination. You’ll receive a written response within seven days of a standard request and within 72 hours if an expedited appeal is granted. Your request will be reviewed by someone within our organization who was not involved in making the coverage determination. This helps ensure that we will give your request a fresh look.
Step 2:
If HealthPartners denies any part of your appeal, you or your appointed representatives have the right to ask an independent organization to review your case. This independent review organization contracts with the federal government and is not part of HealthPartners. You or your appointed representative must make a request for review by the independent review organization in writing within 60 calendar days after the date you were notified of the decision on your first appeal.
Step 3:
If the organization that reviews your case in Step 2 does not rule completely in your favor, you may ask for a review by an Administrative Law Judge. You must make a request for review by an Administrative Law Judge in writing within 60 calendar days after the date of the decision made at Appeal Level 2. The Administrative Law Judge will not review your appeal if the dollar value of the requested Part D benefit is less than $120*. If the dollar value is less than $120, you may not appeal any further.
Step 4:
Your case may be reviewed by the Medicare Appeals Council. The Medicare Appeals Council will first decide whether to review your case. There's no minimum dollar value for the Medicare Appeals Council to hear your case. If you got a denial at Step 3, you or your appointed representative can request review by filing a written request with the Council.
The Medicare Appeals Council does not review every case it receives. When it gets your case, it will first decide whether to review your case. If they decide not to review your case, then you may request a review by a Federal Court Judge (see
Step 5). The Medicare Appeals Council will issue a written notice advising you of any action taken with respect to your request for review. The notice will tell you how to request a review by a Federal Court Judge.
Step 5:
Your case may go to a Federal Court. In order to request judicial review of your case, you must file a civil action in a United States district court. The letter you get from the Medicare Appeals Council in Appeal Level 4 will tell you how to request this review. The Federal Court Judge will first decide whether to review your case.
If the contested amount is $1,220* or more, you may ask a Federal Court Judge to review the case.
*Amount changes annually. This is the amount for 2009.
If you or your provider has questions about your appeal, please contact HealthPartners. Members should call Member Services at 952-883-7979 or 1-800-233-9645. Providers (pharmacies and physicians) should call our Pharmacy Help Line at 952-883-5813 or 1-800-492-7259.