Complaint Procedure
Physicians Health Plan (PHP) works hard to bring you a positive health care experience. We value your insight, and encourage you to report any problems, questions, or concerns that you have with the services you receive. Contact our Customer Service department right away to assist you with any of the following concerns:
- Benefits (including services determined to be experimental, investigational, or not medically necessary/appropriate)
- Eligibility
- Payment of claims (in whole or in part)
- How we've handled payment or coordination of health care services
- Contracts with our health care providers
- Availability of care or providers
- Delivery or quality of health care services you received
Our Customer Service department can be reached from 8:30 a.m. to 5:30 p.m., EST, Monday - Friday, excluding major holidays. You can find the number to call on the back of your member ID card, or you can submit a secure message to PHPMichigan.com/Contact-PHP
The next step, if Customer Service is not able to resolve your concern, would be to submit a request to us in writing.
- Send us a written complaint via paper mail.
- Obtain a Quality of Service Care Form from the Member Reference Desk.
- Have our Customer Service paper mail or email the Quality of Service Care Form to you.
Please send the completed complaint to PHP in one of the following ways:
Via Mail:
Physicians Health Plan
Attn: Complaints
1400 E. Michigan Ave.
PO Box 30377
Lansing, Michigan 48912
Fax: 517.364.8517
Secure Message: PHPMichigan.com/Contact-PHP
If you still feel your concern has not been resolved, the next step would be to file a complaint with the Department of Insurance and Financial Services (DIFS). Contact the DIFS Office of Consumer Services with questions at 877.999.6442, Monday through Friday, from 8 a.m. to 5 p.m. You can also file a written complaint by completing the DIFS complaint form, located on the DIFS website at https://difs.state.mi.us/Complaints/
You may also mail your complaint to:
DIFS – Office of Consumer Services
P.O. Box 30220
Lansing, MI 48909-7720
Fax: 517.284.8837
Email: difs-hicap@michigan.gov
Grievance Procedure
You can appeal a decision that adversely impacts your coverage, including benefit and eligibility determinations. We call this appeal a "grievance". PHP follows the State of Michigan and U.S. Department of Labor Regulations with respect to resolving Appeal/Grievance issues. Customer Service can assist you in filing a grievance, and is also available to answer any questions you have about the grievance process.
How to File a Grievance
If you have a question or concern, call PHP’s Customer Service Department at 800.832.9186. This number is also found on the back of your PHP ID card. We will try to answer your question and solve your problem right away.
- A grievance must be in writing. You can either write a letter or fill out a grievance form, located within the Member Reference Desk. Customer Service can send you a grievance form, if you need it.
- We will let you know that we have received your grievance within five days of receipt. Your case and grievance will be thoroughly reviewed. If we change our decision, we will let you know in writing. If we do not change our decision, you will have the opportunity to ask for a grievance hearing. If a hearing is needed, we will notify you at least one week before the hearing date.
- A special committee will be appointed to hear your grievance. If you want someone to attend the hearing for you, you must let us know in writing prior to your hearing date so we can complete the needed paperwork to allow that person to represent you.
- You and/or your authorized representative have the right to present additional information at the hearing. You or your representative may attend via Webex, telephone, or may choose to not attend.
- If you cannot attend on the date scheduled, you may reschedule by sending your request in writing. We must receive your written request before the originally scheduled hearing date. If we do not receive this written request, we will make a final decision using all information available at that time.
- The PHP grievance process will be completed within a total of 30 days. We will mail you a letter with a final decision.
If you are not happy with our final decision, you have the right to seek external review with the State of Michigan‘s Department of Insurance and Financial Services (DIFS). You must send your request for external review within 127 days from the date you receive PHP’s final decision. You must finish the PHP grievance process before asking for external review, unless there is an urgent situation. We will provide you a copy of the DIFS Request for External Review Form. For more information, you may contact the commissioner at the address provided below.
If your situation meets the definition of urgent under the law, your review will be conducted within 72 hours. Generally an urgent situation is one in which your health may be in serious jeopardy or, in the opinion of your physician you may experience pain that cannot be adequately controlled while you wait for a decision on your appeal.
If you believe your situation is urgent, you may request an expedited appeal by faxing or emailing us your request. You may also request an external review at the same time through the Department of Insurance and Financial Services (DIFS). The address and telephone number are below:
By mail:
DIFS - Office of General Counsel - Appeals Section
PO Box 30220
Lansing MI 48909-7720
By courier or delivery:
DIFS - Office of General Counsel - Appeals Section
530 W Allegan St, 7th Floor
Lansing, MI 48933
Telephone: 877.999.6442
Fax: 517.284.8838
http://www.michigan.gov/difs/
