We provide information to help you understand how your health plan works. You can visit Understanding your benefits, check your Certificate of Coverage document or contact Customer Service at 888.975.8102 (TTY users call 711) if you have questions about any of the items below.

Benefit decisions

Our goal is to cover care that meets high medical standards and is also cost-effective. This is called utilization management. If you have questions regarding our utilization management process and decisions, contact Customer Service and they’ll contact a health management staff member to help. Know that all utilization management decisions are based on appropriateness of care and service, and that no financial incentives exist for issuing denials.

Disease management programs

From diabetes and heart disease to weight management and tobacco cessation, we have programs such as health coaching and Michigan’s free Quitline to help you manage chronic illnesses and improve your health.

Plan basics

Your Certificate of Coverage and Member Handbook has information about:

• The benefits and services included and excluded from coverage
• Copayments and other charges
• Restrictions on services outside the network
• How to submit claims
• How we evaluate new technology for inclusion as a covered benefit
• In-network doctors
• Getting primary care and specialty care like behavioral health and hospital services
• Getting care after normal office hours and receiving emergency care, including when you’re out of our service area

Prescription drug updates

We review new drugs to help make sure that you’re getting safe and effective care. If you take prescription drugs, be sure to read our approved drug list for changes or updates. We also provide information about our prescription coverage and pharmacy management procedures.

Privacy statement

We’re committed to protecting the privacy of our members’ health information in every setting. Our privacy practices protect the privacy, confidentiality and security of your personal health information. If you’re a member of one of our plans, we won’t discuss your health with anyone online or over the phone unless you give us permission. Learn more about how we protect your privacy. For questions or concerns, please contact the Priority Health Privacy Department at patient.privacy@spectrumhealth.org.

Quality performance

You can review summary information about our Quality Improvement Program performance and quality online.

Grievance procedure

If you have any questions or concerns, please call our Customer Service department. Our representatives will help you with your problem as quickly as possible. If you’re not happy with the service or the information you received, you or someone acting on your behalf can send us a formal complaint following our three-step review process.

Rights and responsibilities

Know what you can expect from us and what we expect from you by reading about your rights and responsibilities.

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