view text: smaller | LARGER
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 a grievance or an appeal that you can print and mail to us at:

Grievance and Appeals 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 Appeal” (also known as a Medicaid “State Fair Hearing”)?

A State Appeal is a meeting held by a human services judge (from the MN Department of Human Services Appeals office) with you and South Country Health Alliance. Your meeting will be by telephone unless you ask for a face-to-face meeting.

If you are appealing South Country Health Alliance’s decision to deny, terminate, or reduce a service, or South Country Health Alliance’s decision to deny payment of a claim, and this decision by South Country Health Alliance occurred on or after January 1, 2018, you must appeal to South Country Health Alliance before asking for a State Appeal (if you are appealing a decision that occurred on or before December 31, 2017, the applicable requirements and appeal rights for 2017 will be followed).

You must request a State Appeal in writing within 120 days after the date of the appeal resolution letter that you received from South Country Health Alliance. You must ask for a State Appeal within 10 days of our appeal decision if you want to continue the service during your State Appeal, or before the service is stopped or reduced, whichever is later. You must ask to keep getting your services. If you lose your State Appeal, you may have to pay for these services, but only if state policy allows this.

If South Country Health Alliance takes more time than what is required to give you a decision to your appeal request, and an extension has NOT been added to the appeal timeframe, you do NOT need to wait for an appeal decision from South Country Health Alliance to ask for a State Appeal.

A State Managed Care Ombudsman can provide education and assistance with filing a grievance, appeal, or State Appeal. 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.

 

H2419, H5703_2848a, Approved