Appeals and Grievances

PrimeWest Health provides coverage for quality health care to our members. However, you have the right to make a complaint if you have concerns or problems related to your coverage or care. You also have the right to an explanation from us about any prescription drug, medical care, or service not covered by our plan. There are some legal terms that are used during the Appeals and Grievances process that are helpful to understand. Read the definitions below to learn what these terms mean.

Definitions – words that relate to the Appeals and Grievances process 

Action: This includes any of the following:

• The denial or limited authorization of the type or level of service
• The reduction, suspension, or stopping of a service that was approved before
• The denial of all or part of payment for a service
• Not providing services in a reasonable amount of time
• Not acting within required time frames for Grievances and Appeals
• Denial of a member's request to get services out-of-network for members living in a rural area with only one health plan

Appeal: A written or oral request for review of an Action. You may file an Appeal if you disagree with a decision to deny, terminate, or reduce a request for health care services, prescription drugs, or payment for services or drugs you have already received. For example, you may ask for an Appeal if our plan doesn't pay for a drug, item, or service you think you should be able to receive. You can Appeal to the State as well as PrimeWest Health, but you need to Appeal with PrimeWest Health before filing a State Appeal (also called a Fair Hearing with the State).

Grievance: Expression of discontent about any matter other than an Action. This includes, but is not limited to, discontent with the following:

• Quality of care or services provided
• Failure to respect your rights

Notice of Action: A form or letter we send you telling you about a decision on a claim, a service, or any other Action taken by us.

State Appeal (also called a Fair Hearing with the State): A hearing with a Minnesota Department of Human Services (DHS) Judge to review a decision made by us. You must request a hearing in writing. Call us if you need help with this. You may ask for a hearing if you disagree with any of the following:

• A denial, termination, or reduction of services
• Enrollment in the plan
• Denial in full or part of a claim for a service
• Our failure to act within required timelines for Service Authorizations and Appeals
• Any other Action

Filing requirements – requirements and timelines for filing Appeals and Grievances and information about State Appeals

Plan Appeal (an Appeal to PrimeWest Health): You must Appeal within 65 days after the date we send you a Notice of Action. We can give you more time if you have a good reason for missing the deadline.

• You can call, write, Appeal in person, or fax us. We will give you a written decision within 15 days.
• We may take an additional 4 days if we need more information and it is in your best interest. We will send you a letter telling you we are taking the extra time and the reason why.
• If your Appeal is about an urgently needed service, we will let you know our decision as quickly as your health condition requires, but no later than 72 hours.
• How to keep getting your services while we review your case:
  If we’re stopping or reducing a service, you can keep getting the service while your case is being reviewed. If you want the service to continue during your Appeal, you must ask for an Appeal within 10 days from the date of the Notice of Action or before the service is stopped or reduced, whichever is later. You must also ask to keep getting your services. If you lose your Appeal, you may have to pay for these services but only if State policy allows this.

Grievances: You can file a Grievance at any time.

• If you file an oral Grievance, we will let you know our decision within 10 days; we will send you a letter.
• If you file a written Grievance, we will let you know our decision within 30 days; we will send you a letter.
• We may take an additional 14 days if we need more information and it is in your best interest. We will send you a letter telling you we are taking the extra time and the reason why.

To file an Appeal or Grievance:

Call: 1-866-431-0801. TTY users call 1-800-627-3529 or 711. These calls are free.

Or fax: 1-877-600-4912

State Appeal (also called a Fair Hearing with the State): Before you can ask for a State Appeal, you must Appeal to PrimeWest Health first. You, your representative, or your provider with your written consent, must ask for a State Appeal in writing within 120 days of our Appeal decision. 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.

To request a State Appeal:

Call: 1-651-431-3600 or 1-800-657-3510. TTY users call 1-800-627-3529 or 711. These calls are free.

Or fax: 1-651-431-7523

You can also file online at: https://edocs.dhs.state.mn.us/lfserver/Public/DHS-0033-ENG

For help filing a Grievance, Appeal, or State Appeal, you may call the Ombudsperson for Public Managed Health Care Programs at 1-800-657-3729 (this call is free) or 1-651-431-2660. Ombudsperson staff are neutral and not connected to PrimeWest Health. TTY users call 1-800-627-3529 or 711. These calls are free.

For more information, see your Member Handbook.

Download Member Appeal and Grievance Form

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DHS_Approved_11/21/2025
Updated_01/01/2026