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
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: Fax: 517.364.8517 Secure Message: PHPMichigan.com/Contact-PHP 877.999.6442 https://difs.state.mi.us/Complaints/ 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 Contact the Customer Service Department. If you have a question or concern, call PHP’s Customer Service Department at 800.832.9186
If you are unhappy with the outcome, you may file a formal grievance.
A grievance must be in writing. You can either write a letter or fill out a grievance form, located within the Member Reference Desk
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.
What should you do if you are unhappy with our 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.
There are exceptions for urgent situations. 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: By courier or delivery: Telephone: 877.999.6442 Fax: 517.284.8838 http://www.michigan.gov/difs/