MEMBER RIGHTS (from Minnesota)
1. If you decide to appeal it will NOT affect your eligibility for medical benefits. There is no cost to you for filing a health plan appeal or State fair hearing.
2. If we are stopping or reducing a service, you can keep getting the service if you file a health plan appeal or a State fair hearing within ten days of getting the notice, or before the service is stopped or reduced, whichever is later. The treating provider must agree the service should continue. The service can continue until the appeal or State fair hearing is resolved. If you lose the appeal or State fair hearing, you may have to pay for these services yourself.
3. If you have seen a medical provider who is part of and were told services are not needed, you can get a second opinion. You must see another medical provider.
4. If you have seen a mental health or chemical dependency provider who is part of and have been told mental health or chemical dependency services are not needed, you may get a second opinion. The second opinion must be approved by , and provided by a licensed mental health or chemical dependency provider, who does not need to be a provider.
5. You can have a relative, friend, advocate, provider, or lawyer help with your appeal or State fair hearing. You may present your evidence and facts about the case in person, by telephone, or in writing.
6. You may ask for a decision to be made quickly for urgently needed services.
7. If you ask to see your medical records, or want a copy, your provider or your health plan must provide them to you at no cost. You may need to put your request in writing.
HOW TO REQUEST AN APPEAL OR STATE FAIR HEARING
· We suggest you contact first to talk about the decision but you are not required to do so.
Our phone number is .
You can choose to appeal to the health plan or request a State fair hearing, OR you may do both at the same time. You do not have to finish one process before using another.
· Tell why you disagree with the decision. If you need a decision quickly, state that in your appeal or request for State fair hearing. If you need help, contact at the health plan or the State ombudsman.
You must follow the appeal and State fair hearing time lines.
APPEAL TO
Write to:
____
_
Or call:
· You must appeal within 90 days of receiving this notice.
· If your appeal is about an urgently needed service, we will give you an answer within 72 hours. If we do not agree that the service is urgently needed, we will tell you within 24 hours. If you disagree, you may file a grievance with us or request a State fair hearing.
· If you call us or send us a written appeal we will notify the State ombudsman within three working days. Within 10 days we will tell you that we received your appeal. We will give you a decision within 30 days. We may take up to 14 extra days if we need more information and it is in your best interest.
· You may see your case file, including medical records and other documents considered by us during the appeal process. You may request your case file anytime before or during the appeal.
REQUEST A STATE FAIR HEARING
Write to:
Appeals Office/Department of Human Services
444 Lafayette Road North
St. Paul, MN 55155-3813
Or fax: 651-297-3173
· A hearing officer will hold a meeting. You may attend in person or by phone.
· You must request a State fair hearing in writing within 30 days of receiving this notice. You have up to 90 days if you have a good reason for being late.
· The process can take between 30 and 90 days.
· If your hearing is about a medical necessity denial, you may ask for an expert medical opinion. This will be from an outside reviewer. There is no cost to you.
OMBUDSMAN
A State ombudsman may be able to help with your problem. They can also help you appeal to the health plan or request a State fair hearing.
Write to:
Ombudsman for Managed Health Care Or call (651) 296-1256
Minnesota Department of Human Services toll-free 1-800-657-3729
444 Lafayette Road North
St. Paul, MN 55155-3854
