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If you have called our Customer Service representatives and you are still not satisfied with service you received from Priority
Health or one of our providers or with the answers to a coverage
decision, you or someone acting on your behalf can send us a formal
complaint. This formal complaint is called a grievance.
There are three levels to Priority Health's grievance procedure. If your issue is resolved at one level, you do not need to move to the next level or do anything else. Level 1: Filing a formal grievance Level 2: Filing a formal appeal Level 3: Requesting a state external review How long the process takesIf you have not yet received the services: We must complete both Level 1 and then Level 2 and make a final determination within 30 calendar days after we receive your grievance and appeal forms. The 30-day count does not include any days you or your representative may delay the process. Neither Level 1 nor Level 2 may take more than 15 days each.If you have already received the services: We must complete both levels 1 and 2 combined and make a final determination within 35 calendar days after we receive your grievance and appeal forms. The 35-day count does not include any days you or your representative may delay the process. Neither Level 1 nor Level 2 may take more than 30 days each. NOTE: The grievance process is slightly different for Medicare, MIChild, Medicaid or self-funded members:
Level 1: Filing a formal grievanceQ: How do I file a grievance?
Q: Is there a time limit on filing a grievance? You must file a formal grievance within 2 years of our deciding against your request (an "adverse determination"), or within 2 years of the date you learn of our adverse determination, whichever is later. Q: Who reviews a grievance? First, a group of Priority Health employees well-versed in coverage issues informally reviews your grievance. If they can't resolve it to your satisfaction, they will send your grievance to Priority Health's Grievance Committee. The committee includes Priority Health employees and a medical doctor, none of whom were involved in the initial decision we made or who work directly for someone who made that initial decision. Q: How will I find out the results? You will receive a letter summarizing our findings and resolution. The decision may be all or partly in your favor, or all against you. If you are unhappy with the decision, you may be able to file an appeal. Level 2: Filing a formal appealIf we do not resolve your grievance to your satisfaction, your next step is to appeal our decision.Q: How do I request an appeal? Contact Priority Health Customer Service. They will send you an appeal form or help you fill it out. Q: Is there a time limit for filing an appeal? No. You may file an appeal any time after the grievance decision has been made. Q: Who reviews an appeal? First, a group of Priority Health employees well-versed in coverage issues informally reviews your appeal. If they can't resolve it to your satisfaction, they will send your appeal to Priority Health's Appeal Committee. The committee includes Priority Health employees, Priority Health members, local employers that offer Priority Health to their employees and physicians from the Priority Health network. Review by the Appeal Committee always includes an opinion from a doctor for health issues. The doctor is in the same or related specialty of the health issue being reviewed. Q: When and how will I hear about my review? We will call you. If there is enough time between scheduling and the date of an Appeal Committee meeting, we will send you a letter, too. Q: What happens during the committee's review?
Level 3: Requesting a state external reviewIf you are not satisfied with the resolution of your problem or complaint after completing all levels of the Priority Health Grievance Process, above, you may request a review by the Michigan Office of Financial and Insurance Regulation (OFIR).Q: How do I contact OFIR? You may direct appeals to OFIR at this address and phone number: Office of Financial and Insurance Regulation Health Plans Division 611 West Ottawa, Third Floor P.O. Box 30220 Lansing, MI 48909-7720 877 999-6442 www.michigan.gov/ofir More details about grievances and appeals
You'll find more details about filing a grievance or appeal or asking for a state external review in the coverage documents you received when you enrolled in your Priority Health plan. These documents may include a Certificate of Coverage, policy or summary plan document, plus additional riders that your employer has requested to add or delete some benefits from your particular company plan. Call Customer
Service with questions.
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Last modified
03/02/10
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