The Minnesota Department of Health (Statute 62.D.123 Subd.2.) requires clinics to report to each health plan any written and verbal quality of care complaints the clinic has received from that health plan’s enrollees. (The statute applies to clinic sites located in the state of Minnesota.) Written complaint reports must be submitted quarterly and show all complaints investigated and resolved in the reporting period, or indicate that no complaints were received. The clinic must submit reports by the 15th of the month following the end of each quarter.
Participating providers must comply with Medica’s member complaint resolution process, as required by state and federal laws governing HMOs and insurance companies. Because the member complaint resolution process varies by Medica product and entity, participating providers may call Medica’s Provider Service Center at (800) 458-5512 (option 1, option 1, option 2) for information about member complaint resolution processes.
View Clinic Complaint Reporting Definitions.
View Quality Complaint Reporting Form.
Medica’s Quality of Care Complaint Oversight (QCCO) Committee, an internal peer review body, directs and oversees the quality of care complaint program. The Quality Improvement department investigates quality of care complaints involving clinical or service quality. Qualified staff evaluate each complaint and may request provider input or medical records to validate the allegations. Medica will notify the provider in writing when the investigation is complete.
If the allegations are substantiated, next steps may include, but are not limited to:
- Case closure and tracking to monitor possible trends
- Request for corrective action plan from the provider
- Referral to the Credentialing Subcommittee, Special Investigations Unit, or Legal department for further action
Unsubstantiated allegations are closed and tracked for possible trends.
The QCCO Committee and the Credentialing Subcommittee are regarded as peer review organizations (PRO) under state law. Any communication regarding cases is not subject to subpoena or discovery in any civil action. At the time of the complaint, the member receives an acknowledgement letter (for written, not verbal complaints) but is never informed of the determination as outlined in the
legal requirements relating to the peer review process.
The QCCO Committee and the Credentialing Subcommittee do not make benefit determinations or decisions on reimbursement issues.
A member complaint is a verbal or written expression of dissatisfaction with any aspect of health plan operations, including the delivery of health care services.
A member appeal is a verbal or written request to change an adverse clinical or contractual decision that relates to a medical service, benefit, enrollment or billing issue. A physician practicing in the same or similar area as the treating physician reviews clinical denials, which are based on the member’s contract as well as Medica’s clinical care guidelines and medical policies. Contractual (non-clinical) denials are based on the member’s contract and supporting policies.
Please direct members, who wish to file a complaint or appeal with Medica, to call the customer service phone number listed on the back of their Medica ID card. Members may make complaints by telephone or in writing. Consumer Appeals Advisors, who are trained to help members initiate the complaint or appeal, manage the process, except for members enrolled in Medica’s Medicare plans.
Members who initiate a complaint or appeal will receive a written acknowledgement letter within five working days.
If the complaint is due to health care dissatisfaction, it is forwarded to the appropriate Medica department and evaluated. At that time, the participating provider may be contacted for information relevant to the complaint.
Other kinds of complaints are investigated according to department procedure, involving other Medica departments as appropriate. Responses are provided to members within 10 days if the member initiated the complaint verbally, or within 30 days if the member submitted the complaint in writing.
Members have the right to designate a representative to act on their behalf during the appeal resolution process. A provider may initiate an appeal on behalf of an enrollee with an enrollee’s written permission. Members must sign a Release of Information form acknowledging that the representative has their permission to review confidential information pertinent to their appeal.
Medica has a process in place for resolving expedited appeals. A decision will be made within three days. Notification will be sent within two working days following the decision.
Non-expedited appeals are researched and resolved within 30 days. If the member remains dissatisfied with the first appeal decision, he or she may file a second appeal request. The second level appeal process varies depending on the member’s Medica product. Members of Minnesota fully insured plans also have the option to file a request for external review with their state regulator. Appeals involving clinical (medical necessity) decisions may proceed to external review following the first level appeal decision. Contractual appeals must exhaust the internal second level appeal process before proceeding to external review.
The appeal procedure may vary depending on the member’s product. Check with the Provider Service Center. The Clinical Appeals Department handles appeals that are related to clinical issues only. Any issues regarding coding or reimbursement need to be directed to the Provider Service Center at (952) 992-2232 or (800) 458-5512.
Participating providers may contact the Clinical Appeals Department directly to initiate an appeal request on behalf of a member, except for members covered under Medica’s Medicare products. Any new information about a previously denied service will assist in an accurate and appropriate benefit determination. Written requests for appeal initiation should be directed to:
Clinical Appeals Department
CP420
PO Box 9310
Minneapolis, MN 55440-9310
Fax: (952) 992-8403
In addition to initiating the appeal, a participating provider may direct members to call Medica’s
Member Service Department to initiate the appeal themselves: - For Medica Choice, Elect and Premier, and Medica Insurance Company Choice Select (commercial products), call (952) 945-8000 or (800) 952-3455.
- For Medica Select Solution™, Medica DUAL Solution™ and Medica Prime Solution™ (Medicare products), call (952) 992-2300 or (800) 234-8755.
- For Medica ChoiceCare and MinnesotaCare (state public programs), call (952) 992-2322 or (800)-373-8335.
Member Service will research and explain the reason for the denial (e.g., a direct exclusion in the benefit document). If an appeal is requested, Member Service will assist the member in initiating an appeal for the service.
Return to Provider Responsibilities.