HMO Complaint Information

The following information is Michigan HMO Complaint Data for the year 2013. 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Withdrawn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Withdrawn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 Better Health of MI, Inc.***

69

0

1

70

1.7

0

0

0

0

0

Aetna Health, Inc.

0

0

0

0

0.0

0

0

0

0

0

Amerihealth of MI

0

0

0

0

0.0

0

0

0

0

0

Blue Cross Complete of MI

5

7

71

83

2.3

0

0

0

0

0

Blue Care Network of MI

666

537

17

1240

2.4

11

2

2

0

15

Fidelis SecureCare of MI, Inc.

3

23

0

26

27.3

0

0

0

0

0

Grand Valley Health Plan, Inc.

3

0

5

8

1.6

0

0

0

0

0

Harbor Health Plan, Inc.****

0

0

0

0

0.0

0

0

0

0

0

Health Alliance Plan of MI

2027

562

77

2666

8.0

9

1

0

0

10

HAP Midwest Health Plan, Inc.

52

30

33

125

1.6

0

0

0

0

0

HealthPlus of MI, Inc.

50

115

20

185

2.4

0

0

0

0

0

HealthPlus Partners

6

12

6

24

0.4

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.

216

17

0

233

1.5

1

0

0

0

1

Meridian Health Plan of MI

146

41

0

187

0.6

2

0

0

0

2

Midwest Health Plan, Inc.

0

0

45

45

0.6

0

0

0

0

0

Molina Healthcare of MI

13

29

1780

1822

8.5

1

0

2

0

3

Paramount Care of MI

7

9

10

26

8.2

0

0

0

0

0

Physicians Health Plan

55

153

1

209

6.2

5

1

0

0

6

Physicians Health Plan Family Care

1

3

0

4

0.2

0

0

0

0

0

Priority Health Choice*****

10

1

0

11

0.2

0

0

0

0

0

Priority Health

264

30

8

302

0.8

14

0

1

0

15

Total Health Care, Inc.

0

0

0

0

0

0

0

1

0

1

Total Health Care USA, Inc.

0

2

0

2

0.1

0

0

0

0

0

UnitedHealthcare Community Plan

38

26

469

533

2.2

0

0

10

0

10

Upper Peninsula Health Plan

0

0

2

2

0.1

0

0

0

0

0

Year 2013 Total

3710

1617

2501

7828

2.9

43

4

16

0

63

Percent of Decisions

47.4%

20.7%

31.9%

   

68.3%

6.3%

25.4%

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.
*** Formerly Coventry Cares of Michigan
**** Formerly ProCare Health Plan
***** Formerly Priority Health Government Programs