Grievance and appeals
If you have a question, concern or complaint, please call our Customer Service department at 888.975.8102 (TTY users call 711). If you are not happy with the answers that our representative has provided, you or someone acting on your behalf can send us a formal complaint, also called a grievance. You may also send us a formal request, which is called an appeal.
There are two types of appeals, a standard appeal, which is most commonly used, and a fast or expedited appeal for situations when the time it takes to resolve your request may put your life in danger, interfere with your full recovery or delay treatment for severe pain. Each follows a specific process as outlined below.
Standard appeal procedure
Required steps to request a standard appeal:
- Tell Customer Service that you want to file an appeal. You have 60 days from the date you learn of a problem to file an appeal with us.
- Our appeal committee will look at your request and make a decision. They will send the decision to you in writing. The standard appeal process must be completed with a final decision made within a total of 30 days after we receive your request for review. Up to 14 days can be added to receive information from health professionals or others with information necessary to resolve your concern if it would be to your benefit.
- If you are not happy with the outcome of the standard appeal, you can have your request reviewed by the Department of Insurance and Financial Services (DIFS) in Lansing, Michigan. You may request this review by filling out the External Review Form. The form will be included with the decision from the appeal committee. Your request for an external review must be made within 120 days of our final decision. You may also send your request to the following address:
Department of Insurance and Financial Services Mason Building
530 W Allegan St
P. O. Box 30220
Lansing, MI 48933
Expedited review procedure
If your doctor tells us that the time it takes to resolve your request may put your life in danger, interfere with your full recovery or delay treatment for severe pain, we will follow our expedited review procedure, as outlined below.
- You or your physician must file a request for an expedited review within 10 days of the adverse decision or claim being denied. The expedited review must be completed within 72 hours (three days) of receipt of your request.
- You may also file a request for an expedited review with the Department of Insurance and Financial Services at the same time as filing a request for an expedited review with us.
- If we deny your request for an expedited review, we will tell you within two days of receiving your request. We will also transfer your request to the standard appeal procedure.
If you are not happy with our decision, you may appeal within 10 days of our final decision to the Department of Insurance and Financial Services.