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Appeals and Grievances

PrimeWest Health provides coverage for quality health care to our members. However, you have the right to make a complaint if you have concerns or problems related to your coverage or care. You also have the right to an explanation from us about any prescription drug, medical care, or service not covered by our plan. There are some legal terms that are used during the Appeals and Grievances process that are helpful to understand. Click on the definitions below to read about these terms and what they mean.

Definitions - words that relate to the Appeals and Grievances process (click to expand/collapse)

Action: This includes any of the following:

  • The denial or limited authorization in the type or level of service
  • The reduction, suspension, or stopping of a service that was approved before
  • The denial of all or part of payment for a service
  • Not providing services in a reasonable amount of time
  • Not acting within required time frames for Grievances and Appeals
  • Denial of a member's request to get services out-of-network for members living in a rural area with only one health plan

Appeal: A written or oral request for review of an Action. You may file an Appeal if you disagree with a decision to deny, terminate, or reduce a request for health care services, prescription drugs, or payment for services or drugs you have already received. For example, you may ask for an Appeal if our plan doesn't pay for a drug, item, or service you think you should be able to receive.

Grievance: Expression of discontent about any matter other than an Action. This includes, but is not limited to, discontent with the following:

  • Quality of care or services provided
  • Failure to respect your rights

Notice of Action: A form or letter we send you telling you about a decision on a claim, a service, or any other Action taken by us

State Fair Hearing: A hearing with a Minnesota Department of Human Services (DHS) Judge to review a decision made by us. You must request a hearing in writing. You may ask for a hearing if you disagree with any of the following

  • A denial, termination, or reduction of services
  • Enrollment in the plan
  • Denial in full or part of a claim for a service
  • Our failure to act within required timelines for Service Authorizations and Appeals
  • Any other Action
Filing Requirements - requirements and timelines for filing Appeals and Grievances and information about State Fair Hearings (click to expand/collapse)

Appeals: You must Appeal within 90 days after the date we send you a Notice of Action.

  • You can call or write us. We notify you within 10 days that your Appeal has been received. We will give you a written decision within 30 days.
  • We may take an additional 14 days if we need more information and it is in your best interest. We will send you a letter telling you we are taking the extra time and the reason why.
  • If your Appeal is about an urgently needed service, we will let you know our decision as quickly as your health condition requires, but no later than 72 hours.

Grievances: You must file a Grievance within 90 days from the date of the incident about which you are complaining.

  • If you file an oral Grievance, we will let you know our decision within 10 days; we will send you a letter.
  • If you file a written Grievance, we will let you know our decision within 30 days; we will send you a letter.
  • We may take an additional 14 days if we need more information and it is in your best interest. We will send you a letter telling you we are taking the extra time and the reason why.

To file an Appeal or Grievance:

Write to: Appeals and Grievances
             PrimeWest Health
             2209 Jefferson St, Ste 101
             Alexandria, MN 56308

Or call: 1-866-431-0801 (toll free)

State Fair Hearing: You may request this at any time. You do not have to wait for PrimeWest Health to make a decision regarding your Grievance or Appeal. You must request a State Fair Hearing within 30 days of the date of PrimeWest Health's Notice of Action. (You have up to 90 days if you have a good reason for being late.) The State Fair Hearing process can take between 30 and 90 days.

To request a State Fair Hearing:

Write to: Appeals Office
              Department of Human Services
              PO Box 64941
              Saint Paul, MN 55164-0941

Or fax: 1-651-431-7523

You may also, at any time, file a complaint with the Minnesota Department of Health. To file a complaint with the Minnesota Department of Health:

Write to: Minnesota Department of Health
              Compliance Monitoring Division
              Managed Care Systems
              PO Box 64882
              Saint Paul, MN  55164-0882

Or call: 1-800-657-3916 (toll free) or 1-651-201-5100

For help filing a Grievance, Appeal, or State Fair Hearing, you may call the State Managed Health Care Ombudsman at 1-800-657-3729 (toll free) or 1-651-431-2660. TTY users call 1-800-627-3529 (toll free) or 711 or 1-877-627-3848 (toll free) for the Speech-to-Speech relay service.

For more information, see your Evidence of Coverage.

Download Member Appeal and Grievance Form

PW_2010_049AGR 09_11
DHS_Approval_09/28/2011
Updated_01/03/2012

This information is available in other formats and languages for Minnesota Health Care Programs (MHCP) members. Click here to learn more about how we assure access to care.