Medicare determinations, appeals and grievances

First, send us your request in the way that’s easiest for you. You, your doctor or your legal representative can send your request.

From Oct. 1 through March 31, we’re available 8 a.m. to 8 p.m. CT, seven days a week. From April 1 through Sept. 30, we're available 8 a.m. to 8 p.m. CT, Monday - Friday.

• HealthPartners® Freedom (Cost) plans – 800-233-9645, TTY 711
• HealthPartners^® Journey (PPO) plans – 866-233-8734, TTY 711
• HealthPartners^® Robin (PPO) plans – 866-233-8734, TTY 711
• HealthPartners^® Minnesota Senior Health Options (MSHO) plan – 952-967-7029 or 888-820-4285, TTY 711

After we receive your request, we’ll review it and respond. We provide most responses within 14 days of getting the request. If it’s in your best interest, we may take longer. We’ll let you know if we need more time.

• If we say yes, we’ll approve the agreed-upon coverage within 14 days of getting your request. If we need more time to make our decision, you’ll have coverage by the end of our extended period.
• If we say no, we’ll send you a written statement explaining our decision. We’ll also include information regarding your appeal rights.

If waiting the standard review time will seriously jeopardize your life or health, we’ll respond within 72 hours.

You, your doctor or your legal representative can request coverage for your medicine by completing this Request for Medicare Prescription Drug Coverage Determination form (PDF) . Or you can ask your doctor to fill out this Prior Authorization form (PDF) .

Send completed forms to us in the way that’s easiest for you.

1. Sign in to your online account.
2. Select “Find a form.”
3. Go to the “Medicare” section and find “Request for Medicare prescription drug coverage determination.” Then select “Fill out online.”

After we receive your request, we’ll review it and respond. If you requested a determination about a drug you haven’t received, or if you’re requesting an exception, we’ll respond within 72 hours. If you requested a determination about a payment for a drug you already bought, we’ll respond within 14 calendar days.

If waiting the standard review time will seriously jeopardize your life or health, we’ll respond within 24 hours.

You have 60 calendar days from the date of an initial determination to make an appeal. We may extend this deadline if you have a good reason for needing more time.

Make your appeal in writing. Fill out the appropriate form for the kind of plan you have:

• HealthPartners® Freedom (Cost) (PDF)
• HealthPartners® Journey (PPO) (PDF)
• HealthPartners® Robin (PPO) – Birch and Maple plans (PDF)
• HealthPartners® Robin (PPO) – Glory plan (PDF)
• HealthPartners® Minnesota Senior Health Options (MSHO) (PDF)

You can also request a redetermination of a Medicare Prescription Drug Denial (PDF) .

Send the completed form to us in the way that’s easiest for you.

If you haven’t received care yet, you’ll get a written response to your appeal within 30 days. If you’ve already received the care, you’ll get a response within 60 days (30 days for MSHO plans).

If your appeal is for a Medicare Part B prescription drug, you’ll get a written response within seven calendar days.

If waiting the standard review time will seriously jeopardize your life or health, we'll respond within 72 hours.

If you haven’t received the prescription drug yet, you’ll get a written response within seven days. If you've already purchased the prescription drug and are requesting reimbursement, you'll get a written response within 14 days.

If waiting the standard review time will seriously jeopardize your life or health, we’ll respond within 72 hours.

If we deny your appeal, we automatically send your case to an independent review organization. That organization is not part of HealthPartners. The independent review organization will send you their decision for your appeal.

If you have MSHO, your case is sent to an independent review organization only if the appeal is about Medicare-covered benefits. For Medicaid-covered services, you may:

• Request a State Appeal (Medicaid Fair Hearing with the State)
• Call the Managed Care Ombudsman at 651-431-2660 or toll free at 800-657-3279 (outside the Twin Cities metro area) for help filing a State Appeal (Medicaid Fair Hearing with the State)
• Call the Minnesota Department of Human Services at 651-431-3600 or toll free at 800-657-3510 (outside the Twin Cities metro area)

If we deny your appeal, you can request a reconsideration from an independent review organization. That organization is not part of HealthPartners. We will explain how to request a reconsideration in our appeal decision letter to you.

If the independent review organization from level 2 doesn’t rule in your favor, you can ask for a review by an Administrative Law Judge (also called an ALJ/attorney adjudicator). You must make this request within 60 days of the decision by the independent review organization.

In order for an ALJ/attorney adjudicator to review your appeal, the coverage must be greater than a specified amount. If it’s not, you can’t appeal any further.

If you’re not satisfied with the ALJ/attorney adjudicator’s decision in level 3, you can ask to have your case reviewed by the Medicare Appeals Council. You must file your request within 60 calendar days of the date of receipt of the written ALJ/attorney adjudicator decision or dismissal. The Medicare Appeals Council will decide whether to review your case. They don’t review every case.

If the contested amount is above a specified dollar amount and the Medicare Appeals Council denied your request for review, you can appeal to federal court. To appeal, you need to file a civil action in a U.S. district court. The letter you receive from the Medicare Appeals Council (in level 4) will tell you how to request this review.

You have 60 days from the date of care to file a grievance. However, if you have MSHO, there’s no time limit for filing a grievance. Send us your grievance in the way that’s easiest for you.

The fastest way to let us know about your grievance is to call Member Services.

We resolve most verbal complaints the same day we receive them. However, if you communicate your complaint verbally and we do not resolve it to your satisfaction within a required time frame, we’ll give you additional options, including filing a written complaint.

Fill out the appropriate complaint form for the kind of plan you have:

• HealthPartners® Freedom (Cost) (PDF)
• HealthPartners® Journey (PPO) (PDF)
• HealthPartners® Robin (PPO) – Birch and Maple plans (PDF)
• HealthPartners® Robin (PPO) – Glory plan (PDF)
• HealthPartners® Minnesota Senior Health Options (MSHO) (PDF)

Mail completed forms to:

HealthPartners Member Rights and Benefits
MS 21103R
P.O. Box 9463
Minneapolis, MN 55440-9463

You can also fax completed forms to 952-853-8742.

After we receive your complaint, we’ll review it and respond. Our Member Rights and Benefits team will notify you within 10 days that we received your complaint.

We’ll send our response within 30 days of receiving your complaint form. If it’s in your best interest, we may take an additional 14 days to respond to your concerns. We’ll let you know if we need an extension.