HMO Complaint Information
The following information is Michigan HMO Complaint Data for the year 2007. Complaints can range from a consumer disagreeing with a denial of service to dissatisfaction with the service they received. An HMO is responsible for reviewing and responding to all complaints.

Please note that Medicaid members also have an external complaint process with the Michigan Department of Community Health (MDCH). This chart does not contain information from MDCH.
 
Definitions: Internal   The first formal review process conducted by the HMO
  External   The review process conducted by OFIR after a consumer has completed the HMOs internal review process. This process is called the Patients Right to Independent Review Act (PRIRA).
  Upheld   The decision of the HMO was upheld by the process.
  Overturned   The decision of the HMO was overturned by the process.
  Compromise   A mutually agreeable decision was reached.
  Resolved   The final adverse determination was reversed prior to a formal decision by OFIR.

If you have questions, please contact the Office of Financial and Insurance Regulation toll free at 877-999-6442.
 
HMO Complaint Information
    Total Level One Determinations*   External PRIRA Determinations**
Name of HMO
Upheld
Overturned
Compromise
Total
Annualized level one complaints per 1,000 members
Upheld
Overturned
Resolved 
Other#
Total
Aetna Health, Inc. 6 2 0 8 7.6 0 0 0 0 0
BlueCaid of MI 8 5 0 13 0.7 0 0 0 0 0
Blue Care Network of MI 631 619 27 1,277 2.0 29 8 0 0 37
CareSource Michigan 3 0 77 80 1.6 0 0 0 0 0
DaVita VillageHealth of MI 0 0 0 0 0.0 0 0 0 0 0
Fidelis SecureCare of MI, Inc. 0 0 19 19 23.3 0 0 0 0 0
Grand Valley Health Plan, Inc. 4 1 4 9 0.9 0 1 0 0 1
Great Lakes Health Plan 11 1 0 12 0.1 3 1 0 0 4
Health Alliance Plan of MI 339 872 108 1,319 3.2 11 3 0 0 14
Health Plan of MI 144 64 0 208 1.6 1 0 0 0 1
HealthPlus of MI, Inc. 102 153 51 306 3.4 0 0 0 0 0
HealthPlus Partners 14 22 3 39 0.6 0 0 0 0 0
McLaren Health Plan, Inc. 78 0 0 78 1.3 0 0 0 0 0
Midwest Health Plan, Inc. 2,900 1,300 1,070 5,270 82.8 0 0 0 0 0
Molina Healthcare of MI, Inc. 98 116 2,035 2,249 10.4 1 0 0 0 1
OmniCare Health Plan 261 2 0 263 4.6 0 0 0 0 0
Paramount Care of MI 16 17 35 68 8.4 1 0 0 0 1
PHP of Mid-Michigan 157 200 0 357 6.5 15 7 0 0 22
PHPMM-Family Care 15 19 0 34 2.0 0 1 0 0 1
PHP of South Michigan 10 10 0 20 1.2 2 0 0 0 2
Priority Health Govt. Programs 7 0 1 8 0.2 1 0 0 0 1
Priority Health Plan 399 159 19 577 1.4 21 4 0 0 25
ProCare 0 0 0 0 0.0 0 0 0 0 0
Total Health Care, Inc. 45 5 20 70 1.3 0 0 0 0 0
Total Health Care, USA 1 0 1 2 0.2 0 0 0 0 0
Upper Peninsula Health Plan 86 3 5 94 3.7 0 0 0 0 0
Year 2007 Total 5,335 3,570 3,475 12,380 4.8 85 25 0 0 110
Percent of Decisions 43.1% 28.8% 28.1%              
 

*  The source of Level One Determinations is data submitted by the HMOs to the Office of Financial and Insurance Regulation.
** The source of External PRIRA Determinations is the Office of Financial and Insurance Regulation.