GRIEVANCES AND APPEALS OF GRIEVANCE RECEIVED BY CUSTOMER SERVICES
For more information on the Grievance and Appeal Process, see the Member Handbook located under the MEMBER tab on the website
A grievance is defined as a complaint (oral or written expression of dissatisfaction) submitted by or on behalf of a member. HAP Midwest Health Plan accepts grievances from any individual the member authorizes in writing to represent them including, but not limited to, a physician. Grievances include concerns related to:
  • Quality of health care services, including safety issues
  • Access and availability of care, including a grievance regarding an adverse determination made pursuant to utilization review
  • Attitude and service of practitioners, providers and office staff, ancillary services, etc.
  • Benefits or claims payment, handling or reimbursement for health care services
Filing Grievance or Appeal of a Grievance:
All members receive written information at the time of their enrollment with HAP MHP which outlines the process available to assist them with filing a Grievance or Appeal of a Grievance. A member may file (or have filed on his/her behalf) a Grievance or Appeal of a Grievance verbally by calling the toll-free number of #1-888-654-2200 for HAP MHP. A member may also file a written Grievance or Appeal of a Grievance by documenting the issue and faxing it to 248-663-3774, or visiting on site or mailing it directly to the Customer Services Department at the HAP MHP corporate office at:
  • HAP Midwest Health Plan
  • Attn: Customer Service Department
  • 21700 Northwestern Hwy
  • Southfield MI 48075
HAP MHP Customer Services representatives are available to give enrollees assistance in completing forms and taking other procedural steps. HAP MHP provides written and verbal interpreter services and TTY/TDD toll-free numbers. HAP MHP acknowledges receipt of each Grievance or Appeal of a Grievance in writing.

Investigation: HAP Midwest Health Plan ensures a full and complete investigation of all grievances/appeals, including consideration of materials submitted by the member.

Filing Timeframes and Methods:
All initial Grievances and Appeals of a Grievance must be filed up to 60 days of the member’s date of discovery of the problem, complaint or aggrieved situation. All Appeals of a Grievances must be filed not more than 60 days after the date of HAP MHP’s decision. Grievances or Appeal of a Grievance may be filed in writing, by telephone, or in person at HAP MHP’s corporate office. HAP MHP assists members to document their Grievance or Appeal of a Grievance request as needed. Members have the right to submit written information or other materials for consideration with their Grievance or Appeal of a Grievance.

Authorized Representative:
The member may authorize an individual of their choosing to represent or assist them in their Grievance or Appeal of a Grievance including their practitioner. HAP MHP requires members to designate their representative in writing. A member may also file a written Grievance or Appeal of a Grievance by documenting the issue and faxing it to 248-663-3771, or visiting on site or mailing it directly to the Customer Services Department at the HAP MHP corporate office at:
  • HAP Midwest Health Plan
  • Attn: Customer Service Department
  • 21700 Northwestern Hwy
  • Southfield MI 48075
Administrator and Contact Person at Midwest Health Plan: The contact person or designee for HAP MHP is the Manager of Customer Services.

External Appeal Avenues: The Medicaid member has the right to request a fair hearing with the Michigan Department of Health and Human Services, after the Plans Internal Appeal process has been exhausted. The member has 120 days to request a State Fair Hearing. The member may request a hearing by calling 1-800-642-3195 or in writing to:
  • Administrative Tribunal
  • Michigan Department of Health and Human Services
  • P.O. Box 30763
  • Lansing, MI 48909-7695
In addition, the member has the right to request a review by DIFS after they have exhausted HAP MHP’s internal Appeal process. The member has 120 days to file, in writing, a request for an external review from DIFS:

The member may request an external review by DIFS for the following circumstances:
  • If the member remains dissatisfied with the resolution outcomes from the Appeal processes, he/she has the right to request an external review by DIFS. A member must exhaust HAP MHP’s internal Grievance and Appeal process prior to requesting an external review.
  • If HAP MHP has not issued a written decision within the 30-day time frame and without the agreement of the covered person to a delay, the member may request an external review.
For an external expedited review, the member must file with HAP MHP prior to filing with DIFS, this can be immediately after filing with HAP MHP, and the reviews can be concurrent.

The written notice of the right to request an external review of Appeal of a Grievance determination issued before the service is provided to a member shall be in plain language and include the following:
  • A statement informing the covered person of their right for an expedited external review if HAP MHP does not issue a decision within the required time frame.
  • A copy of the description of the standard and expedited external review procedures highlighting the procedures that give the member the right to submit additional information, including forms used to process an external review.
  • FIS Form 0018 Health Care-Request for External Review
The written final determination notice of the right to request an external review for Appeal of a Grievance determination shall be in plain language and shall include the standard external review procedures information required above, and shall be provided in a manner prescribed by the Director. The address and phone number for filing a request for external review at DIFS is Department of Insurance and Financial:

DIFS
Office of General Counsel – Appeals Section
Mail - P.O. Box 30220
Lansing, Michigan 48909-7720
Courier/delivery - 530 W. Allegan Street 7th floor
Lansing, MI
Fax - 517-284-8838
Phone: 1-877-999-6442
Email - DIFS-HealthAppeal@michigan.gov


Or you may fax information to fax #1-517-241-4168, or www.michigan.gov/DIFS

All requests must be made in writing.

APPEALS DUE TO ADVERSE COVERAGE DETERMINATION PROCEDURE:

When HAP MHP makes a decision subject to an Adverse Benefit Determination Appeal a written Adverse Benefit Determination notice is sent to the enrollee and the requesting provider, if applicable. Adverse Benefit Determination notice for the suspension, reduction or termination of services are provided at least 12 days prior to the change in services.

Adverse Benefit Determination Appeals Time frame Standards:

Appeal Type Timeframe
Pre-service Grievance 30 calendar days from date of pre-service Grievance request to date of notification.
Post-service Grievance 30 calendar days from date of the post service request to date of notification.
Expedited Pre/Post Grievance Up to 72 hours from date of request to date of notification.

  1. When the request for non-urgent pre-service or post-service care is denied by the HAP MHP Medical Director, HAP MHP gives members written notification of the decision. The member (or authorized representative) is notified of their Adverse Benefit Determination Appeal rights and procedure. The member (or authorized representative) has up to 60 calendar days to file an Adverse Benefit Determination Appeal.
  2. Investigation: HAP MHP ensures a full and complete investigation of all Adverse Benefit Determination Appeals. Members may submit written comments, documents or other information for consideration during the Adverse Benefit Determination Appeal process.