Member Rights and Responsibilities/Complaint and Grievance Procedures

Your Rights

Enrollment with PHP entitles you to:

  1. Receive information about your rights and responsibilities as a member.
  2. Be treated at all times with respect and recognition of your dignity and right to privacy.
  3. Choose and change a Primary Care Physician (PCP) from a list of network Physicians or Practitioners.
  4. Information on all treatment options in terms you can understand so you can give informed consent before treatment begins.
  5. Participate in decisions involving your health care, such as having treatment or not and what may happen.
  6. Voice complaints or file appeals without fear of punishment or retaliation and/or without fear of loss of coverage.
  7. Be given information about PHP, its services, and the Providers in its network, including their qualifications.
  8. Make suggestions regarding PHP's member rights and responsibilities policies.

Your Responsibilities

As a covered person, you are expected to:

  1. Select or be assigned a Primary Care Physician from PHP's list of network Providers and notify PHP when you have made a change.
  2. Be aware that all hospitalizations must be approved in advance by PHP, except in emergencies or for urgently needed health services.
  3. Use Emergency Department services only for treatment of a serious or life-threatening medical condition.
  4. Always present your PHP ID card to Providers each time you receive services, never let another person use it, report its loss or theft to us and destroy any old cards.
  5. Notify PHP of any changes in address, eligible family members and marital status, or if you acquire other health insurance coverage.
  6. Provide complete and accurate information (to the extent possible) that PHP and Providers need in order to provide care.
  7. Understand your health problems and developing treatment goals you agree on with your PHP Provider.
  8. Follow the plans and instructions for care that you agree on with your PHP Provider.
  9. Understand what services have cost shares to you, and pay them directly to the network Provider who gives you care.
  10. Read your PHP member materials and become familiar with and follow health plan benefits, policies and procedures.
  11. Report health care fraud or wrongdoing to PHP.

Complaint and Grievance Procedures

PHP encourages your comments so that we can continue to improve our service to you. While we hope there are no problems with our service, issues may sometimes arise.

If you are unhappy with the service or care you receive while a PHP member, we want to know about your experience. You may contact Customer Service through our Contact Us Form, write us a letter or call us toll-free at 800.832.9186. We will investigate your situation and respond to your concern quickly.

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 help you file a grievance, if necessary.

How to File a Grievance

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. 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