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South Country Health Alliance | Appeals and Grievances

Appeals and Grievances

What is an “appeal”?

An “appeal” is when you ask South Country Health Alliance to review a decision we made to deny, terminate, or reduce a service or deny payment for a service. You can file a written or oral appeal.

What is a “grievance”?

A “grievance” is when you have a complaint about anything other than a decision made by South Country Health Alliance. For example, grievances may be filed about the quality of care or services you received, rudeness of a provider, or health plan staff not respecting your rights. You can file a written or oral grievance. The process for filing a grievance is detailed in your Evidence of Coverage/Member Handbook.

How to File an Appeal or Grievance

Member Services will assist you in filing an appeal or grievance if you want their help. Keep in mind, an appeal or grievance must be submitted within certain time limits, as specified in your Evidence of Coverage/Member Handbook.

There are forms below for submitting either an appeal or grievance that you can print and mail to us at:

Complaints, Appeals, and Grievances South Country Health Alliance 2300 Park Drive, Suite 100 Owatonna, MN 55060

Or fax to 1-507-444-7774

Or call Member Services

For AbilityCare and SeniorCare Complete Members

For Medical Assistance, MinnesotaCare, Minnesota Senior Care Plus, SingleCare, and SharedCare Members

What is a “State Fair Hearing (SFH)”?

This is when you ask the “state” to review a decision made by your health plan. You can file a SFH any time during the process, and you do not have to file an appeal with South Country before you ask for a SFH. You must request a SFH in writing within 30 days after the date of the notice you received denying, reducing, or terminating a service or payment. You have up to 90 days if you have a good reason for being late.

A State Managed Care Ombudsman can provide education and assistance with filing a grievance, appeal, or SFH. You can call or write to the Ombudsman for State Managed Health Care programs any time during this process.

Managed Care Ombudsman Hotline: 1-800-657-3729 or 1-651-431-2660

Or write: Minnesota Department of Human Services Ombudsman for State Managed Health Care Programs PO Box 64941 St. Paul, MN 55164-0249

You can also file a complaint with the Minnesota Department of Health.

Call: 1-800-657-3916 (toll free)

Or write: Minnesota Department of Health Health Policy and Systems Compliance Division Managed Care Systems PO Box 64882 St. Paul, MN 55164-0882

For complete details on the Appeals and Grievances process, see your Evidence of Coverage or Member Handbook. For members of SeniorCare Complete and AbilityCare, see Chapter 9. For members of Medical Assistance, Minnesota Senior Care Plus, MinnesotaCare, SingleCare, or SharedCare see Section 13.

How to get an aggregate number of grievances, appeals, and exceptions filed with South Country

To find out about the total number of grievances, appeals, and exceptions received by South Country Health Alliance for your program, call Member Services.

 

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