Member Appeal and Grievances
DEFINITIONS:
Action: A denial or decrease of a requested service. This includes, but is not limited to: denial or decrease in the type or level of service, 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 or denial of a request by a rural area enrollee for services outside of the network in areas where there is only one health plan.
Appeal: An oral or written request to PrimeWest for review of an Action. This request may also be from your provider acting on your behalf with your written consent.
Grievance: A written or oral expression of discontent about any matter other than an Action; including but not limited to, the quality of care or service provided or 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 PrimeWest.
State fair hearing: A hearing at the State to review a decision made by PrimeWest. You must request a hearing in writing.
FILING REQUIREMENTS:
Appeals – You must appeal within 90 days of receiving a Notice of Action.
- You can call or write us. We will send a copy of your appeal to the State Managed Care Ombudsman within three days of when we receive it. 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 call us, we will let you know our decision by phone within 10 days.
- If you write us, 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.
Send your letter regarding your Appeal or Grievance to:
PrimeWest Health System
Appeals and Grievances
2209 Jefferson St, Ste 101
Alexandria, MN 56308
or Call: 1-866-431-0801
State fair hearing – You may request this at any time. You do not have to wait for PrimeWest to make a decision regarding your Grievance or Appeal. You must request a State fair hearing within 30 days of PrimeWest's last 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.
Write to:
Appeals Office, Department of Human Services
444 Lafayette Road North
St. Paul, MN 55155-3813
or Fax: 651-297-3173
You may also, at any time, file a complaint with the Minnesota Department of Health.
Write to:
Minnesota Department of Health
Managed Care Systems
85 E 7th Place, Suite 400
P.O. Box 64882
St. Paul, MN 55164-0882
or call: 1-800-657-3916 or 651-282-5600
For help filing a grievance, appeal or State fair hearing, you may call the State Managed Health Care Ombudsman at 651-296-1256 or toll free 1-800-657-3729.
For more information refer to your Certificate of Coverage.
Download Member Appeal and Grievance Form.