Grievance Process

Care Choices HMO promotes high quality and efficient health care by reviewing requests for medical services.

To make payment determinations, Care Choices HMO considers all available information and in situations involving medical necessity, we involve actively practicing physicians whose specialty is the same or similar to the physician who will or did provide care or performed a procedure. Care Choices HMO also involves other clinical and health care professional staff as each situation requires.

In the event that Care Choices HMO denies payment for a service, there are steps you can take to have the adverse determination reconsidered.

What to do if you disagree with an adverse determination

There are two ways you can have Care Choices HMO's decision to deny payment for care or services reconsidered:

Standard Grievance Process
You can ask Care Choices HMO to reconsider its own adverse decision by filing a grievance.
OFIS External Review Process
If you still disagree with Care Choices HMO's final decision, you may request an independent external review with the Michigan Office of Financial and Insurance Services (OFIS).
Expedited Grievance Process

Important: You must first ask Care Choices HMO to reconsider its original adverse decision by following the Standard Grievance Process before you can ask for an external review by OFIS.

Standard Grievance Process

The Care Choices HMO Standard Grievance Process and the OFIS External Review Process are described in detail as follows:

You or your authorized representative, who may be your attorney, doctor, family member or friend, may file a grievance within two years of the date you received written notification of the Care Choices HMO adverse determination. Care Choices HMO will reconsider its adverse determination and make a final determination no later than the thirtieth (30) calendar day for pre-service grievances and post-service grievances after you submit a grievance request.

The steps of the Care Choices HMO Standard Grievance Process:

Step 1: CALL CUSTOMER SERVICE

Call Care Choices HMO's Customer Service department and ask them to send you a Grievance Filing Form. If you need help with the form our Customer Service Coordinators are available to help you. He or she will send the Grievance Filing Form within five business days. If the Customer Service Coordinator completes the form for you, he or she will send the form within five business days to you for your review and signature.

Step 2: MEMBER RECONSIDERATION COMMITTEE

When Care Choices HMO receives your signed Grievance Filing Form, we will send you a written acknowledgement. The Care Choices HMO staff will fully investigate your case. If the care or services being reconsidered involve medical necessity issues, your physician will be asked to submit additional information. Where appropriate, a physician specialist in active practice will review all available information and make a recommendation to the Care Choices HMO Member Reconsideration Committee, which will conduct the reconsideration of our original adverse determination.

Care Choices HMO will notify you no later than 10 days prior to the Committee meeting and will give you the date, time and place of the meeting. You may attend and participate in person or by telephone. You may have a person represent you or submit written comments, documents or other information relating to the grievance.

Within the thirtieth (30) calendar day for pre-service and post-service grievances from the date Care Choices HMO received your completed Grievance Filing Form, we will send you a written notice of our reconsidered decision. Upon request, you can obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion and copies of all relevant documents on which the grievance decision was based. Additionally upon request a list of titles and qualifications of individual(s) participating in the appeal review along with the names of the medical experts whose advise was obtained on behalf of Care Choices HMO in connection with the grievance decision will be made available to you. If you do not receive a written notice from Care Choices HMO in the specified timeframe, the Care Choices HMO standard grievance process is considered complete and you may then move on to the next step.

OFIS External Review

If you completed steps 1 and 2 of the Care Choices HMO Standard Grievance Process and if you continue to disagree with the Care Choices HMO reconsidered adverse decision, you may then request that the Michigan Office of Financial and Insurance Services (OFIS) arrange for an independent, external review of your case. You must make your request to the OFIS within 60 days of the Care Choices HMO Member

Step 1: OFIS EXTERNAL REVIEW

Only after steps 1 and 2 are completed should you complete the Health Care Request for External Review form. Once completed you should attach a copy of Care Choices adverse determination notice to the form and send it to the following address:

Office of Financial and Insurance Services
Michigan Division of Insurance,
Health Plans Division
611 West Ottawa, Second Floor
P.O. Box 30220
Lansing, Michigan 48909-7720
Toll free phone: (877) 999-6442
Fax: 517 241-4168

Please fill in the form completely. Additionally please complete the Health Plan Authorization for Release of Personal and Health Information form and return it back to:

Care Choices HMO
Resolution Coordinator Customer Services
34605 12 Mile Road
Farmington Hills, Michigan 48331

Neither Care Choices HMO nor your doctor can release your protected health and medical information to OFIS without your written permission. You or your representative may submit additional information that you believe is important. You are not financially responsible for costs of the external review.

Expedited Grievance Process

An expedited grievance can only be requested before the care or service is provided to you or while the care or service is being provided to you.

If your doctor thinks that this adverse determination seriously jeopardized your health the entire process can be completed within 72 hours or less.

When an expedited grievance is requested your physician will need to substantiate either orally or in writing that the timeframe for the standard grievance process would acutely jeopardize your health, life, your ability to regain maximum function or would subject you to severe pain that could not be adequately managed without the care or treatment that is the subject of the grievance.

Care Choices HMO will make an initial expedited reconsideration decision within 72 hours after we receive your expedited grievance request or as expeditiously as your health warrants.

At the same time, you may request an expedited external review with OFIS. You should call the OFIS office at (877) 999-6442.

If you do not request an expedited external review at the same time you request a Care Choices HMO expedited reconsideration, you may still request that OFIS complete an expedited external review. You must request the expedited external review within 10 days of receiving Care Choices HMO final adverse determination at the number provided above.

Customer Service Department
(800) 852-9780
Monday through Thursday
8:30 AM - 6:00 PM
Friday 9:00 AM - 6:00 PM

Hearing, Speech and Interpreter Assistance
Care Choices TDD: 248-489-5033
Michigan Relay Center: (800) 649-3777