Medicare Part D: The Medicare prescription drug benefit program. We call this program “Part D” for short. Medicare Part D covers outpatient prescription drugs, vaccines, and some supplies not covered by Medicare Part A or Medicare Part B or Medical Assistance. Our plan includes Medicare Part D.Medicare Part A: The Medicare program that covers most medically necessary hospital, skilled nursing facility, home health, and hospice care.
Medicare Part B: The Medicare program that covers services (such as lab tests, surgeries, and doctor visits) and supplies (such as wheelchairs and walkers) that are medically necessary to treat a disease or condition. Medicare Part B also covers many preventive and screening services.Medical Assistance: This is the name of Minnesota’s Medicaid program. Medical Assistance is run by the state and is paid for by the state and the federal government. It helps people with limited incomes and resources pay for long-term services and supports and medical costs.
It covers extra services and some drugs not covered by Medicare. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Grievances and Appeals

What is a “health plan appeal”?

A health plan appeal is an oral (by phone or in person) or written request that you make to us, asking us to review a decision we made that you disagree with. Some examples include (this is not a complete list): a denial of a prior authorization or coverage request for a drug, item or service; the reduction, suspension, or stopping of an authorized (approved) service, before the authorization ends (such as homecare services); denial of payment of a claim (also referred to as a claim appeal; this is when a provider bills South Country for a service or item you already received from the provider (referred to as a claim) and South Country denies payment to the provider); denial of a request for out of network services when living in a rural area with only one health plan; a denial of your request to dispute financial liability that you feel you do not owe (such as a copay or cost sharing).

What is a “grievance”?

A grievance is an oral (by phone or in person) or written request that you make to us, when you are not satisfied with a service you received from us or one of our network providers or pharmacies. Some examples include (this is not a complete list): the quality of care or services provided to you, a failure to respect your rights, rude behavior, a service or treatment delay or a late decision for a coverage request or appeal. The process for filing a grievance is detailed in your 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 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
6380 West Frontage Road
Medford, MN 55049

Or fax to 1-507-444-7774

Or call Member Services

For AbilityCare and SeniorCare Complete Members

For Families and Children, MinnesotaCare, Minnesota Senior Care Plus, SingleCare and SharedCare Members

What is a “state appeal” (also known as a Medicaid “Fair hearing with the state”)?

A state appeal is a meeting held by a human services judge (from the Minnesota 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.

You must appeal to South Country Health Alliance first, before asking for a state appeal.

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.

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.

A Public Managed Care Ombudsperson can provide education and assistance with filing a grievance, appeal or state appeal. You can call or write to the Ombudsperson for Public Managed Health Care Programs any time during this process.

Ombudsperson for Public Managed Health Care Programs Hotline: 1-800-657-3729 or 1-651-431-2660

Or write:
Minnesota Department of Human Services
Ombudsperson for Public Managed Health Care Programs
PO Box 64249
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
Managed Care Section
PO Box 64882
St. Paul, MN 55164-0882

For more details on the Appeals and Grievances process, refer to your Member Handbook.

  • For members of SeniorCare Complete and AbilityCare, refer to Chapter 9.
  • For members of Medical Assistance, Minnesota Senior Care Plus, MinnesotaCare, SingleCare, or SharedCare refer to Section 13.

Requests for Part C Grievance and Appeal Data for Members Enrolled in SeniorCare Complete or AbilityCare

South Country members enrolled in SeniorCare Complete or AbilityCare have the right to request information about the number of Part C (Medicare) appeals and grievances we receive.

You may submit your request to our Grievance and Appeals department in one of the following ways:

Phone: Call Member Services toll-free at 1-866-567-7242 (TTY: 1-800-627-3529 or 711) (Member Services will then send your request to our Grievance and Appeals department)

Email: grievances-appeals@mnscha.org

Fax:1-507-444-7774

In person or by mail:
South Country Health Alliance
Grievance and Appeals Department
6380 West Frontage Road
Medford, MN  55049

CONTACT US

Member Services
Toll Free: 1-866-567-7242
TTY: 1-800-627-3529 or 711

Mon-Fri 8am to 5pm

For SeniorCare Complete & AbilityCare
8am-8pm, 7 days a week, October - March
8am-8pm, Mon-Fri, April - September

members@mnscha.org

H2419, H5703_5772 Accepted 8/9/21

Last Updated on 04/02/2024 by Chris Gartner

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