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FirstPlan Blue no longer offers health coverage. The list of providers at left is for informational purposes and outstanding claims.

FirstPlan Blue Related Information

Service Area (Counties in Minnesota)
Carlton, Cook, Koochiching, Lake and St. Louis counties.

Grievances, Coverage Determinations, Appeals and Exceptions
You have the right to a health plan appeal OR to request a State Fair Hearing, OR you may do both at the same time. You do not have to finish one process before using another. You may have different appeal options depending on if you have Medicare. We suggest that you contact us first about the decision or your options, but you are not required to. You may contact Customer Service at (218) 724-3083 or toll free at 877-736-5518. TTY users should call (218) 727-9870, Monday through Friday, from 8 a.m. to 6 p.m.

To exercise your right to a health plan appeal , file your appeal within 90 calendar days after the date of this notice. We can give you more time if you have a good reason for missing the deadline.

To exercise your right to a State Fair Hearing, file your appeal within 30 days of receiving this notice. You have up to 90 days if you have a good reason for being late. The process can take between 30 and 90 days.

Who May File a Health Plan Appeal OR State Fair Hearing?
You or someone you name to act for you (your authorized representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others also already may be authorized under State law to act for you.

If you want someone to act for you, you and your authorized representative must sign, date and send us a statement naming that person to act for you.

IMPORTANT INFORMATION ABOUT YOUR HEALTH PLAN APPEAL RIGHTS
For more information about your appeal rights, call us or see your Certificate of Coverage.

There are Two Kinds of Appeals You May File
Standard (30 days) – You can ask for a standard appeal. Within 10 days we will tell you that we received your appeal. We must give you a decision no later than 30 days after we get your appeal. (We may extend this time by up to 14 days, if you request an extension or if we need additional information and the extension benefits you. We will tell you if we are taking the extra time and why . )

Fast (72 hours review) – If this notice is about medical coverage, you can ask for a fast appeal if you or your doctor believe that your health could be seriously harmed by waiting too long for a decision. We must decide on a fast appeal no later than 72 hours after we get your appeal. (We may extend this time by up to 14 days if you request an extension, or if we need additional information and the extension benefits you.) If we do not agree that the service is urgently needed, we will tell you within 24 hours. If you disagree, you may file a grievance with us or request a State Fair Hearing.

  • If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 30 days could seriously harm your health, we will automatically give you a fast appeal.
  • If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal. If we do not give you a fast appeal, we will decide your appeal within 30 days.

What Do I Include With My Appeal?
You should include your name, address, Member ID number, reasons for appealing, and any evidence you wish to attach. Tell why you disagree with the decision. If you need a decision quickly, state that in your appeal. If you need help, contact Member Services or the State Ombudsman. You may send in supporting medical records, doctors’ letters, or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal. You may send this information or present this information in person if you wish. You may see your case file, including medical records and other documents considered by us during the appeal process. You may request your case file anytime before or during the appeal. You may also request, free of charge, a copy of the guidelines or criteria used in making this decision.

How Do I File An Appeal?

For a Standard Appeal: You or your authorized representative can file an appeal orally or in writing. Call us at (218) 740-2330 or toll free at 800-635-4159 Monday through Friday, 8 a.m. to 4:30 p.m. We may write your appeal and may send a letter stating what you told us. You may be asked to sign this letter and return it to us before a final decision can be made.

OR you may mail, fax or deliver your written appeal to the address(es) below:
525 S. Lake Ave Suite 222
Duluth , MN 55802

OR you can fax to (218) 740-4618

For a Fast Appeal: You or your authorized representative should contact us by telephone or fax: (218) 740-2330 or toll free at 800-635-4159 , TTY (218) 724-3083, Monday through Friday, 8 a.m. to 6 p.m.

What Happens Next?
If you appeal, we will review our decision. After we review our decision, if any of the services or claims payments requested are still denied, you can request a State Fair Hearing with the Minnesota Department of Human Services. For a Medicare covered service, Medicare will provide you with a new and impartial review of your case by a reviewer outside of your Medicare Advantage Organization. If you disagree with that decision, you have further appeal rights. You will be notified of those appeal rights if this happens.

Contact Information:
If you need information or help, call us at:
Toll Free:800-635-4159
TTY: (218) 724-3083
Hours: Monday – Friday, 8 a.m. to 4:30 p.m .

Other Resources to Help You if You have Medicare:
Medicare Rights Center
Toll Free: 1-888-HMO-9050

Elder Care Locator
Toll Free: 1-800-677-1116

1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048

Total Number of Complaints, Appeals and Exceptions
If you would like to inquire as to the total number of complaints, appeals, and exceptions received by this Plan, call:
Toll Free: 1-800-635-4159
TTY/TDD users should call: 218-724-3083
8 a.m. until 4:30 p.m. Monday through Friday, CST

Out of Network Coverage
Medically necessary Out of Network Services will be covered when one of the following occurs:
• When you require Medical Emergency Services
• When you require Post-Stabilization Care Services to maintain, improve or resolve your condition; or
• You are Out of Service Area and require Urgent Care

Quality Assurance, Medical Therapy Management and Drug Utilization
For information related to Quality Assurance, Medical Therapy Management and Drug Utilization, please use the MSHO Drug Formulary and Pharmacy Finder links to go to the Prime Therapeutics website.

Potential for contract terminations
All health plans in the Medicare program agree to stay with the program for a full year at a time. Each year the plans decide whether to continue for another year. Even if a Medicare health plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for health care coverage in your area and will give you information about your rights to other Medicare coverage. You can choose another health plan if one is available.

FirstPlan Blue MSHO is a Special Needs Plan offered under Medicare Advantage by FirstPlan of Minnesota, a health plan with a Medicare contract. This program is offered in conjunction with the State of Minnesota under contact with Centers for Medicare and Medicaid Services (CMS). Participation in the program is limited to beneficiaries who have both Medicare and Medicaid coverage and are age 65 or older. Drug coverage benefits are subject to limitations.

FirstPlan Blue Basic is a special needs plan offered under Medicare by FirstPlan of Minnesota, a health plan with a Medicare contract. This program is offered in conjunction with the State of Minnesota under contract with Centers for Medicare and Medicaid Services (CMS). Participation in the program is limited to people with disabilities age 18 to 64. Drug coverage benefits are subject to limitations.