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	Withdrawn	Case removed from consideration before decision issued.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of HMO	Upheld	Overturned	Compromise	Total	Annualized level one complaints per 1,000 members	Upheld	Overturned	Resolved	Withdrawn	Total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.