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For Members

Complaints And Grievances

Please select from the 2 choices below:
Commercial Members
Former PHPSWM Medicaid Members

Commercial Members

We encourage your comments and suggestions so that we continue to improve our service to you. While we hope that there are no problems with our services, one may occasionally arise. In this case, we have a grievance procedure created to resolve your problem as rapidly and efficiently as possible.

STEP 1:
If you have a concern or question regarding any aspect of the Company, including the provision of health services or benefits, contact the Customer Service Department. A Customer Service Specialist will try to answer your question or solve your problem through informal procedures.

STEP 2:
If you are not satisfied with the resolution of your question or concern through informal procedures and your question or concern constitutes a Grievance, you have the right to request a formal review of your grievance by the Grievance Committee. The Customer Service Specialist can provide you with information needed to initiate the internal grievance process. You may authorize in writing, an Authorized Representative to act on your behalf at any state of the grievance proceeding.

The Company will let you know it has received your grievance. The Company will appoint a committee to hear your grievance and will inform you or your Authorized Representative of the date and time for the Grievance Committee hearing. You or your Authorized Representative will have the right to present your grievance and to provide additional information at the hearing.

If you are, or your Authorized Representative is, unable to attend the hearing in person or via teleconference, and you wish to delay your hearing, you must submit your request for a delay, in writing, to the Company prior to the start of the hearing. If you do not provide written notification of a request for delay prior to the start of the hearing, the Company will make a final determination on your grievance based on the information available to it at the time of the hearing, whether or not you or your Authorized Representative appear at the hearing.

Unless you have provided a written request for a delay, the Company will send you its final determination, in writing, within 30 calendar days from the date your grievance was received by the Company. It will tell you the reasons for the determination.

STEP 3:
If you are not satisfied with the final determination made by the Company, you have the right to seek external review by the Insurance Commissioner pursuant to MCL 500.2213. You must submit your request for external review within 60 days from the date you receive the Company's final determination. The Company will provide a copy of the Office of Financial and Insurance Services (OFIS) Request for External Review Form. For additional information you should contact the Commissioner at the address provided at the end of this section.

You must finish the Company grievance process before asking for an external review, unless there is an urgent situation as described below.


Expedited Grievance:
The above grievance procedures do not apply if you have a dispute with the Company over an upcoming health service which, in the opinion of a physician, needs to be treated as an expedited grievance. In urgent situations:

  1. The physician must substantiate to the Company, verbally or in writing, that the usual timeframe for a grievance would seriously jeopardize your life, health or ability to regain maximum function.

  2. The Company will inform both you and your physician of its decision within 72 hours after the physician notifies the Company of the urgent situation. If our determination is provided verbally, we will put it in writing no later than 2 business days after notification.

  3. For urgent situations, you may ask for review by the Insurance Commissioner pursuant to MCL 500.2213 at the same time that you go through the Company's grievance process. For information about requesting review of an urgent situation by the Insurance Commissioner you should contact:

Medicaid Fair Hearing Process

Please note: This process applies to issues prior to September 1, 2006. If you have an issue after that date, contact Great Lakes Health Plan.

We hope that you will give us a chance to respond to your concerns by following this process. You do not have to follow this process. You can ask the State of Michigan to review the problem within 90 days of the problem. This is called an Administrative or Fair Hearing. The PHPSWM Customer Service department can send you the Administrative Hearing form. They will also help you fill out the form if you need them to. You may also call MI ENROLLS, 1-888-367-6557, to have a form sent to you.

The steps for the State's Administrative (Fair) Hearing process are:

  1. Fill out the hearing form and return it to the address listed on the form.
  2. You will be sent a letter telling you when and where your hearing will be held.
  3. The results will be mailed to you after the hearing. If your complaint is taken care of before your hearing date, you must call to ask for a hearing request withdrawal form. You can call 1-800-642-3195 to ask for this form.