Minnesota Health Insurance Appeals and Grievances

What is an internal appeal?

An internal appeal asks the health plan to reconsider an adverse determination—a denial of coverage, payment, or prior authorization. Minnesota law also uses complaint for many grievances (Minn. Stat. § 62Q.69).

This is different from external review, where MDH or Commerce assigns an independent reviewer after internal steps are complete (with exceptions for urgent cases).

General walkthrough: Appeals roadmap. Minnesota specifics below.

Minnesota appeal timelines

Which statute applies depends on the issue (PA vs. general complaint) and plan type (individual, group, HMO).

Prior authorization appeals (ch. 62M)

• Standard PA appeal: written decision within 15 days of the appeal notice (up to 4 additional days in limited circumstances) (§ 62M.06, subd. 3)
• Expedited PA appeal: telephone appeal when care is ongoing; decision within 72 hours ( § 62M.06, subd. 2)
• Denial notices must explain external review rights (§ 62M.06, subd. 2(c), 3(h))

Complaints and grievances (§§ 62Q.69–62Q.70)

• Written complaint decision: as soon as practical, but no later than 30 days (up to 14 extra days with notice) (§ 62Q.69, subd. 3(a))
• Oral complaints not resolved within 10 days may be put in writing with plan assistance (§ 62Q.69, subd. 2(a))
• Group plans: after an adverse complaint decision, internal appeal within 30 days (written appeal) or 45 days (hearing) (§ 62Q.70, subd. 3)
• Many individual plans: adverse complaint decisions may go directly to external review under § 62Q.73 (§ 62Q.69, subd. 3(c)); some carriers voluntarily follow the group appeal process

Medical issues in complaints

Grievances requiring a medical determination are processed under the PA appeal procedures in § 62M.06 (§ 62Q.68, subd. 2).

How to file

1. Read the adverse determination for the appeal deadline, phone number, and required format.
2. Submit a written complaint or appeal (or request a hearing for group plans) with medical records and a provider letter.
3. Request expedited review if urgent harm is likely—especially for ongoing care or post-emergency services.
4. Keep copies of everything submitted and the date sent.

Carrier links: Minnesota prior auth & internal appeals links.

You may also contact the appropriate commissioner at any time during a complaint (§ 62Q.69, subd. 3(d)).

Evidence that helps

• Treating provider letter on medical necessity
• Clinical records and the plan's review criteria (request under § 62M.05 or § 72A.285)
• Peer-reviewed literature for experimental/investigational disputes

See Building a strong appeal packet.

Medicaid appeals

Medical Assistance and MinnesotaCare managed care use MCO grievance and appeal processes first (often 90 days to file an appeal). After the MCO decision, you may request a state fair hearing with the Department of Human Services—generally within 120 days of the MCO appeal resolution notice under federal Medicaid rules, and within 30 days (90 with good cause) of a county or state agency notice under Minn. Stat. § 256.045.

Use DHS form DHS-0033 or contact your county human services agency. External review under § 62Q.73 does not replace Medicaid fair hearings (§ 62Q.73, subd. 2).

More: Medicaid managed care appeals.

After internal appeal

If the plan upholds the denial, you may request external review within 6 months of the adverse determination (§ 62Q.73, subd. 3(d)).

Next: Minnesota external review.