Fully funded group plan grievance process
Note: This grievance process applies only if you're a member of a fully funded employer group health plan. Choose the Priority Health plan you have from the menu on the right to see the process that applies to you.
If you have called our Customer Service representatives and you are still not satisfied with the 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 the Priority Health grievance procedure. If your issue is resolved at one level, you don't 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 takes
If we receive your form during non-business hours, we count the day we receive it as the next business day.
If you have not yet received the services: We must make a final determination on your Level 1 grievance within 15 calendar days and your Level 2 appeal (if any) within 15 calendar days of the dates we receive your grievance and appeal forms. This 30-day combined total does not include any days you or your representative may delay the process.
If you have already received the services: We must make a final determination on your Level 1 grievance within 30 calendar days and your Level 2 appeal (if any) within 30 calendar days of the dates we receive your grievance and appeal forms. This 60-day combined total does not include any days you or your representative may delay the process.
Level 1: Filing a formal grievance
You must file a formal grievance within 180 calendar days of our deciding against your request (an "adverse determination"), or within 180 calendar days of the date you learn we made the adverse determination, whichever is later.
First, read the grievance process outline:
Second, send us your grievance in ONE of these four ways:
- Fill out the online Grievance form.
- Fill out a paper form:
Group HMO-POS Plan Grievance Form
Group PPO Plan Grievance Form
OR call Customer Service at the number on the back of your membership card and ask us to mail one to you. It includes instructions on how to mail or fax it back to us.
- Type up your request without using the form and fax it, with documentation, to us at 616.975.8894, or email it to PHGrievance@spectrumhealth.org.
- Call the number on the back of your membership card and one of our Customer Service representatives will complete a verbal grievance/appeal on your behalf.
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 people on the Grievance Committee that makes the final decision on your grievance are not the same individuals who made the initial decision against you.
A review by the Grievance Committee always includes getting a doctor's opinion on your health issues.
How will I find out the results?
We send you a letter summarizing our findings and resolution. The decision may be all or partly in your favor, or all against you. If the decision is all or partly against you, you may file an appeal for us to reconsider the decision again.
Level 2: Filing a formal appeal
To appeal a grievance decision, use the appeal form we include when we notify you of our decision on your Level 1 grievance. You can also call Priority Health Customer Service at the number on your membership ID card. They'll send you an appeal form or help you fill one out.
You must file a formal appeal within 90 days of the date on the grievance decision letter.
What happens during an appeal?
When you request an appeal, a group of Priority Health employees well-versed in coverage issues informally reviews it. If they can't resolve it to your satisfaction, they will send your appeal to the Priority Health Appeal Committee.
The people who make the final decision on your appeal are not the same people who made the decision on your grievance.
When your appeal goes to Committee review
You may participate in the Committee review by phone, or be present in person, or have someone represent you by phone or in person. During the review, you or your representative are invited to speak to the Appeal Committee and explain why you believe we should reconsider our previous decisions.
Review by the Appeal Committee always includes an opinion from a doctor on your health issues.
You will also get a copy, free of charge, of the material the committee will review. You will get a phone call and letter with our decision within 5 days after the hearing.
Level 3: Requesting a state external review
If you are not satisfied with the resolution of your problem or complaint after completing all levels of the Priority Health Grievance Process, you may request a review by the Michigan Department of Insurance and Financial Services (DIFS).
Michigan Department of Insurance and Financial Services Health Plans Division611 West Ottawa, Third Floor
P.O. Box 30220
Lansing, MI 48909-7720
You'll find more details 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.