Grievance, Appeals, & State Fair Hearing Process

You can contact Member Services to file a Grievance (complaint) or Appeal if you disagree with a decision or have a complaint about your medical benefits or the services you received. You can also contact the Minnesota Department of Human Services to request a State Appeal (State Fair Hearing) after exhausting the Appeal process through IMCare. You have up to 120 days after the Appeal decision by IMCare to request a State Appeal (State Fair Hearing). See your MSHO Member Handbook (PDF) for a complete description of the Itasca Medical Care Grievance, Appeals, and State Appeal process.

You may call Member Services about your Grievance or Appeal at 800-843-9536. TTY users can call 800-627-3529 or 711. Calls to these numbers are free. Hours are: October 1 - March 31, 7 days a week, 8 a.m. - 8 p.m.; April 1 - September 30, Monday - Friday, 8 a.m. - 8 p.m.

You may also send a fax to 218-327-5545 (toll free).

You may send a letter about your Grievance or Appeal to Itasca Medical Care at the following address:

• Itasca Medical Care Appeals and Grievances
  1219 SE 2nd Avenue
  Grand Rapids, MN 55744-3983

You may call the Ombudsman for State Managed Care Programs at the Minnesota Department of Human Services about your Grievance or Appeal or to request a State Fair Hearing at 800-657-3729 (toll free) or 1 651-431-2660.

You may send a written request for a State Fair Hearing after you exhaust the Grievance or Appeal process through IMCare to the following address:

• Minnesota Department of Human Services
  Appeals Office
  P.O. Box 64941
  Saint Paul, MN 55164-0941

To file an Appeal about your Medicare Part D benefits, you may call Member Services about your Grievance or Appeal at 800-843-9536. TTY users can call 800-627-3529 or 711. Calls to these numbers are free. Hours are: October 1 - March 31, 7 days a week, 8 a.m. - 8 p.m.;         

April 1 - September 30, Monday - Friday, 8 a.m. - 8 p.m.

You may also send a fax to 218-327-5545.

Grievances

A Grievance is any complaint, other than one that involves a request for an initial determination or an Appeal. Grievances do not involve problems related to approving or paying for medical care, services, Part D or non-Part D drugs, problems about having to leave the hospital too soon, and problems about having Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) services ending too soon.

Problems That May Lead to a Grievance

• Problems with the service you receive from Member Services
• You feel that you are being encouraged to leave (disenroll from) the Plan;
• We don't give you required notices;
• You believe our notices and other written materials are hard to understand;
• Waiting too long for prescriptions to be filled;
• Waiting too long on the phone, in the waiting room, or in the exam room;
• Problems getting appointments when you need them or waiting too long for them;
• Rude behavior by network pharmacists or other staff;
• Cleanliness or condition of network pharmacies;
• We fail to respect your rights;
• You disagree with our decision not to give you a "fast" decision or a "fast" Appeal;
• We don't give you a decision within the required time frame;

If you have one of these types of problems and want to make a complaint, it is called "filing a Grievance."

Filing a Grievance With Our Plan

If you have a complaint, you or your representative may call Member Services at 800-843-9536. TTY users can call 800-627-3529 or 711. Calls to these numbers are free.

Hours are: October 1 - March 31, 7 days a week, 8 a.m. - 8 p.m.;

April 1 - September 30, Monday - Friday, 8 a.m. - 8 p.m.

We will try to resolve your complaint over the phone. We will give you a decision within 10 days. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If you ask for a written response, file a written Grievance, or your complaint is related to quality of care, we will respond in writing to you.

If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the written Grievance process. You can mail or fax a letter about your Grievance to the following:

Mail

Itasca Medical Care Appeals and Grievances

1219 SE 2nd Avenue

Grand Rapids, MN 55744-3983

Fax

218-327-5545 

We will notify you within 10 days that the Grievance has been received.  We must address your Grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. We will tell you within 30 days that we are taking extra time and the reasons why. If we deny your Grievance in whole or in part, our written decision will explain why we denied it and will tell you about any dispute resolution options you may have.

Fast Grievances

You have the right to ask for a “fast” or “expedited” Grievance. You may file a fast or expedited Grievance orally or in writing. We will respond to your oral or written Grievance within 24 hours.

Filing a Grievance Through the Beneficiary & Family Centered Care Quality Improvement Organization (BFCC QIO)

You may complain about the quality of care received under Medicare, including care during a hospital stay. You may complain to us using the Grievance process, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC QIO), or both. In Minnesota, the BFCC QIO is called LIvanta. You may contact Livanta at 1-888-524-9900 (toll free) or write to:

• Livanta BFCC-QIO Program
  10820 Guilford Road
  Suite 202
  Annapolis Junction, MD 20701
• Toll-free Beneficiary Helpline: 1-888-524-9900 or TTY 1-888-985-8775
  Fax: 1-833-868-4059.
  Livanta website

Filing a Grievance with the Centers for Medicare & Medicaid Services (CMS)

We encourage you to contact Itasca Medical Care Member Services first if you have a Grievance. However, you can also tell Medicare about your Grievance directly by visiting the Centers for Medicare & Medicaid Services (CMS) website. You may also call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TTD users can call 1-877-486-2048. Calls to these numbers are free.

Who May File a Grievance

You or someone you name may file a complaint (Grievance) or Appeal for you. The person you name would be your “appointed representative.” You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act for you. Other people may already be authorized by the Court or under State law to act for you. If you want someone to act for you who is not already authorized by the Court or State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. You may call Member Services to learn how to name your appointed representative. You may also fill out the Appointment of Representative Form (PDF). Once you have filled out the form, you may print and mail or fax the form to:

Mail

Itasca Medical Care Appeals and Grievances

1219 SE 2nd Avenue

Grand Rapids, MN 55744-3983

Fax

218-327-5545

Total Number of Complaints Filed to the Plan

To find out about the total number of Grievances, Appeals, and exceptions received by this plan, call Member Services at 1-800-843-9536. TTY users can call 1-800-627-3529 or 711. Calls to these numbers are free. Hours are: October 1 – March 31, 7 days a week, 8 a.m. – 8 p.m.; February 15 – September 30, Monday – Friday, 8 a.m. – 8 p.m. 

CMS Appeal and Grievance Data Form

Civil Rights Notice and Language Block

Organization Determinations

An organization determination is when IMCare makes any decision regarding

whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are also called “coverage decisions” in the MSHO Member Handbook. Go to Chapter 9 in your MSHO Member Handbook (PDF) for a more detailed explanation, or call IMCare Member services at 218-327-6188 and we can assist you.  

 An enrollee, the enrollee’s representative, or the enrollee’s doctor or other prescriber can request a coverage determination.  A request for a coverage determination can be made orally or in writing, and they can be standard or expedited. 

• Standard organization determinations are made as expeditiously as the member’s health condition requires, not to exceed 14 calendar days (10 business days) from the date the request was received. 
• Expedited organization determinations are made as expeditiously as the member’s health condition requires, not to exceed 72 hours from the date the request was received. Expedited organization determinations are for cases where the provider indicates or IMCare Classic (HMO) determines that following the standard time frame could seriously jeopardize the member’s life or health, or ability to attain, maintain, or regain maximum function.

H2417 IMCARECLASSIC_114 CMS_Approved 04/04/2017

Last Updated_06/10/2019