HMO Complaint Information

The following information is Michigan HMO Complaint Data for the year 2012. 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 Department of Insurance and Financial Services (DIFS) 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 DIFS.

 

Withdrawn

 

Case removed from consideration before decision issued.


If you have questions, please contact the Department of Insurance and Financial Services 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 
Withdrawn
Total

Aetna Health, Inc.

0

0

0

0

0.0

0

0

0

0

0

Blue Cross Complete

8

4

0

12

0.6

0

0

0

0

0

Blue Care Network of MI

894

786

28

1708

3.2

17

2

2

0

21

Coventry Cares of Michigan

68

0

0

68

1.5

0

0

0

0

0

Fidelis SecureCare of MI, Inc.

0

1

0

1

1.2

0

0

0

0

0

Grand Valley Health Plan, Inc.

5

1

0

6

0.9

0

0

0

0

0

Health Alliance Plan of MI

571

525

72

1168

3.4

3

1

1

0

5

HealthPlus of MI, Inc.

45

112

38

195

2.6

0

0

0

0

0

HealthPlus Partners

15

18

13

46

0.7

0

0

0

0

0

Humana Medical Plan of MI

0

0

0

0

0.0

0

0

0

0

0

McLaren Health Plan Community

0

0

0

0

0.0

0

0

0

0

0

McLaren Health Plan, Inc.

150

18

0

168

1.2

0

0

0

0

0

Meridian Health Plan

231

101

0

332

1.1

0

0

3

0

3

Midwest Health Plan, Inc.

0

0

45

45

0.6

0

0

0

0

0

Molina Healthcare

23

32

1274

1329

6.0

0

0

0

0

0

Paramount Care of MI

10

11

32

53

11.5

1

1

0

0

2

Physicians Health Plan

119

77

0

196

5.6

4

2

1

0

7

Physicians Health Plan Family Care

13

15

0

28

1.6

0

0

0

0

0

Priority Health Govt. Programs

7

1

0

8

0.1

0

0

0

0

0

Priority Health Plan

399

35

4

438

1.1

13

1

0

0

14

ProCare

0

0

0

0

0.0

0

0

0

0

0

Total Health Care, Inc.

8

6

136

150

2.7

1

0

0

0

1

Total Health Care USA, Inc.

8

0

10

18

0.6

0

0

0

0

0

United Healthcare Community Plan

30

17

579

626

2.6

0

0

1

0

1

Upper Peninsula Health Plan

2

0

2

4

0.1

0

0

0

0

0

Year 2012 Total

2606

1760

2233

6599

2.4

39

7

8

0

54

Percent of Decisions

39.5%

26.7%

33.8%

   

72.2%

13.0%

14.8%

0%

 

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