STATE OF MINNESOTA
COMPLAINT, GRIEVANCE AND INDEPENDENT REVIEW RIGHTS
How to file a Complaint:
You have the right to file a complaint regarding any dissatisfaction you experience with your health plan. We encourage you to contact a customer service representative if you have an inquiry, concern, or complaint against us, or one of our participating providers. The customer service representative acts as an intermediary to resolve any of your issues. You may contact Customer Service at (800) 362-3310.
You may also file a complaint in writing to:
840 Carolina St.
Sauk City, WI 53583
Fax: (608) 644-3500
We will investigate your complaint and will provide you with a resolution within 10 business days of receipt of your complaint. If we cannot resolve your verbal complaint to your satisfaction, we will inform you of your right to file your complaint in writing and will provide you with a Complaint form to complete and return to us. Customer Service is available to provide assistance in completing and submitting a Complaint Form and will promptly mail the completed form to you for your signature.
We will notify you of our decision in writing within 30 days of the date of receipt of your written complaint. If a decision in writing cannot be made within 30 days due to circumstances outside of our control, we may take an additional 14 days to notify you; we will inform you in advance of additional time along with reasons for the extension. If the decision is partially or wholly adverse, we will notify you of your right to appeal our decision through our internal appeals process.
You may also submit a complaint to the Minnesota Department of Health (MDH), a state agency that enforces Minnesota’s Health Maintenance Organization laws at any time. To request a complaint form, you can contact the MDH by calling (800) 657-3916 or visit their website at http://www.health.state.mn.us/
If you have questions or require language assistance, please call Customer Service. For people who are deaf, hard of hearing or speech impaired, please call TTY 711 or toll free 800-877-8973, or you may call through a video relay service company of your choice. Interpreter services are provided free of charge to you.
How to file a Pre-Service or Non-Clinical Appeal:
If you disagree with our decision to deny or partially deny a request for service or course of treatment, you are entitled to a full and fair review by individual associated with us, but not involved in making the initial decision.
You or your authorized personal representative may file an appeal by submitting a written request within 180 days following receipt of a notification of an adverse benefit determination. If you fail to submit your appeal within the 180 day timeframe, you lose your right to appeal. You may provide us with additional information that relates to your claim or request for service and you may request or receive copies of information we used to make the initial denial, including the diagnosis and treatment codes and their corresponding meaning, free of charge.
If you wish to authorize another person, including an attorney, to act on your behalf, and with whom you want us to communicate, we require your authorization in writing. You may use our Personal Representative Appointment and Authorization to Release Protected Health Information Form or you can provide us with your own written expression of authorization and include it with your written appeal request. Representation is not required and you are not required to use the form to appoint an authorized representative.
Your written appeal request should include:
- Date of your appeal request;
- Your printed name and address (if you designated an authorized representative, the and address of your authorized representative);
- Your Gundersen Health Plan identification number (from your Gundersen Health Plan identification card);
- Any information or documents to support your appeal request; and
- Your signature.
Send your written appeal request with all supporting information to:
840 Carolina St.
Sauk City, WI 53583
Fax: (608) 644-3500
For pre-service appeals involving medically urgent situation, you may request an expedited appeal, either orally or in writing. Expedited appeals will be conducted as expeditiously as your health condition requires, but no later than 72 hours from the receipt of your request. Expedited appeal means a situation where (1) the duration of the standard appeal process could seriously jeopardize your life or health or your ability regain maximum function; (2) in the opinion of your physician; you may experience severe pain that cannot be adequately controlled without the care or treatment, and (3) your physician requests an expedited appeal.
If you believe your situation is urgent, you may request an expedited appeal verbally by calling Gundersen Health Plan Minnesota’s Appeals Specialists at (800) 362-3309 extension 101901.
External Review Rights
In addition to your right to file a complaint or appeal concerning your claim or benefit denial, you or someone you name to act for you (your authorized representative) may also be entitled to an external review by medical professionals who have no connection to Gundersen Health Plan to address your concerns. External review requests must be submitted in writing to the Minnesota Department of Health (MDH) at the following address: Managed Care Section, Po Box 64882, St. Paul, MN 55164-0882. A $25.00 filing fee made payable to Minnesota Department of Health is required. (Fee may be waived by the MDH in cases of financial hardship). To learn more about the external review process in Minnesota, please review Section 7 – Complaint, Appeal & External Review Procedures of your Certificate of Coverage.
When can you request an external review?
You must first exhaust Gundersen Health Plan’s internal appeal process before you can initiate an external review. You must submit your request for an external review within 6 months of the date of the adverse decision. You may obtain an external review if the decision involved:
- The admission, availability of care, continued stay, or other health care service that is a covered benefit;
- The denial reduction or termination of payment for a service because we determined it did not meet the requirements for medical necessity, health care setting, level of care or effectiveness of the health care service or treatment requested;
- The decision was based on a determination that the service or treatment in investigational or experimental; or
- Upon agreement by us to waive your request for exhaustion of the internal grievance process requirement. If waived, you or your authorized representative may file a request in writing for a standard external review.
You may be entitled to an expedited independent review if:
- You have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed,
- The final adverse determination concerns an admission, availability of care, continued stay, or a health care service which you received emergency services, but have not been discharged from a facility; or
- The denial to provide or pay for a health care service or a course of treatment is based on the determination that the service or treatment is experimental or investigational and if your treating physician certifies in writing that delaying the service or treatment would render it significantly less effective, you may also have the right to request an expedited external review.
How do you file a request for external review?
You may obtain a Request for External Appeal form by contacting Gundersen Health Plan Minnesota’s Appeals Specialist in person at Gundersen Health Plan, 3190 Gundersen Drive, Onalaska, WI 54650 or by calling the Appeals Specialists at (800) 362-3309 extension 101901, or by submitting your request by fax at (608) 644-3500, Attn: Gundersen Health Plan Minnesota Appeals Specialist.
You may also obtain the Request for External Appeal form by phone, email or by submitting a written request to the Minnesota Department of Health, Managed Care Systems Section, Po Box 64882, St. Paul, MN 55164-0882, by phone (651) 201-5100 or (800) 657-3916 or by emailing: firstname.lastname@example.org
What if I have more questions about the external review process?
To learn more about the external review process in Minnesota, please review the fact sheet on Understanding Your Grievance and Independent Review Rights or reference Section 7 – Appeal & External Review Procedures of your Certificate of Coverage. This section contains valuable information regarding the external review process.
Information regarding your external review eligibility may also be obtained on the Minnesota website at http://www.health.state.mn.us/divs/hpsc/mcs/external.htm or if you have questions on how to request an external review, contact our Appeals Specialists at (800) 362-3309 extension 101901.
If you require language assistance at no cost to you, please call Customer Service at (800) 362-3310. For people who are deaf, hard of hearing or speech impaired, please call TTY 711 or toll free 800-877-8973 or you may call through a video relay service company of your choice. Interpreter services are provided free of charge to you.