To better serve our members, we would like to know your questions, concerns, or complaints. Use the telephone number shown on the back of your PHP FamilyCare ID card to provide us with your comments. If you are not satisfied with the response from Customer Service, we encourage your comments so that we can continue to improve our service to you. While we hope that there are no problems with our service, sometimes, one may happen.
If PHP FamilyCare makes a decision you disagree with, you have the right to appeal that decision. We have an appeal process to resolve your issue fairly and quickly.
How to file an appeal:
1.Contact the Customer Service Department.
- If you have a question or concern, call PHP FamilyCare’s Customer Service Department at the telephone number on the back of your PHP FamilyCare ID card. We will try to answer your question and solve your problem right away.
2.If you are not happy with our decision, you may file a formal appeal.
- If you are unhappy with the outcome of your issue, you have the right to appeal our decision by filing an appeal. You may either write a letter, use the PHP Appeal Form, or call PHP FamilyCare Customer Service for assistance.
- We will let you know that we received your appeal letter or form within 5 days from the date we receive it. Your issue will be reviewed. If we change our decision, we will let you know in writing. If we do not change our decision, we will invite you to attend an Appeal Hearing. If a hearing is needed, we will tell you the date and time of the hearing at least one week before the hearing date.
- We will appoint a special committee to hear your issue. If you want someone to attend the hearing for you, you must let us know that in writing a week before the 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 in person, or by telephone, or may choose to not attend.
- If you cannot attend on the date scheduled, you may reschedule. You should contact us by telephone to let us know and arrange a new date. We will ask you to send your request in writing. We must receive your request in writing before the scheduled hearing date. If we do not, we will make a final decision about your issue at the scheduled hearing time using all information available at that time.
- The PHP FamilyCare appeal process should be completed within 30 days. We will mail you a letter with a final decision within 30 days from the date we receive your written grievance. It should not be longer than 30 days unless you asked to change the date of the hearing.
3. What to do if you are unhappy with our Final Decision about your Issue.
If you are not happy with our final decision, you have the right to seek external review with the State of Michigan, Office of Financial and Insurance Regulation (OFIR). You must send your request for external review within 60 days from the date you receive PHP FamilyCare's final decision. You must finish the PHP FamilyCare appeal process before asking for external review, unless there is an urgent situation.
We will provide you a copy of the OFIR Request for External Review Form. For more information, you may contact the Commissioner at the address provided below.
4. There are Exceptions for Urgent Situations.
If a physician believes your issue is urgent due to a risk to your life or health, there is a quicker process to resolve your issue.
- The Doctor needs to notify PHP FamilyCare, verbally or in writing, to confirm that an urgent situation exists.
- PHP FamilyCare will tell you and your doctor of our final decision with 72 hours after the doctor notifies PHP FamilyCare of the urgent request. If our initial decision is not in writing, we will put it in writing no later than two business days after telling it to you.
- For urgent situations, you may ask for an external review at the same time you go through the PHP FamilyCare appeal process. For more information about requesting a review of an urgent situation by the Insurance Commissioner, contact the address below:
Office of Financial and Insurance Regulation
Division of Insurance, Health Plan Division
611 West Ottawa, Second Floor
P.O. Box 30220
Lansing, MI 48909.7720
Telephone: 1.877.999.6442
Website: www.cis.state.mi.us/ofis
Administrative Tribunal
Michigan Departmant of Community Health
PO Box 30763
Lansing, Michigan 48909
Telephone: 1-517-877-833-0870