To Report Problems and Appeal Decisions

Reporting Problems to the Upper Peninsula Health Plan (UPHP)

Upper Peninsula Health Plan (UPHP) wants you to be happy with us and our providers. If you are not happy with UPHP or your health care, call UPHP Customer Service. Our staff will listen and try to answer your question or solve your problem. If we are unable to resolve the problem, you may file a grievance. A grievance is a complaint you let us know about. A grievance is a complaint about anything other than a denied, reduced or ended service. You may file a grievance if you have a problem calling the plan or if you are unhappy with the way a staff person or provider treated you.

For example, you may file a grievance if:

• You were unhappy with the quality of care or treatment you received.
• Your doctor or their staff was rude to you.
• Your doctor or staff did not respect your rights.

You can file a grievance by calling UPHP Customer Service 1-800-835-2556 or by writing us at:

Upper Peninsula Health Plan
Attn: Customer Services
853 W. Washington Street
Marquette, MI 49855

You can have someone you know represent you or act on your behalf. The person will be “your representative”. If you decide to have someone represent you or act for you, you will need to inform UPHP in writing. UPHP will let you know we have received your grievance. UPHP will provide a written decision to you within 90 days of receiving your grievance.

To Appeal Medical Decisions

Approving care your doctor asks for is based on medical need.  UPHP does not reward providers for denying care or under-using services.

If you are not happy with a medical decision by UPHP, you may ask for an appeal.  You will learn in writing that UPHP has received your request within 5  days of receipt.  UPHP will review your appeal.  You will have a final decision in writing within 30 days.

If a 30-day timeline would be a serious threat to your life or health, your primary care provider (PCP) or another provider must call UPHP Clinical Services at 1-800-835-2556 and ask for an expedited appeal.  You will get a fast decision within 72 hours.

You must give written consent for someone to act for you in an appeal.

• Appointment of Representative Form

You can call or write to UPHP when you want to appeal a denial by calling Customer Service at 1-800-835-2556 (TTY: 711) or in writing to:

Upper Peninsula Health Plan
Attn: UM Review and Appeals Coordinator
853 W. Washington Street
Marquette, MI 49855
Fax: 1-906-225-7720

If needed, our appeals staff can help you file an appeal.

To Report Problems to the State

If you want to appeal a decision about medical need, and you have finished the UPHP grievance and appeal process, you may also do so, within 127 days of receiving our final decision by writing to:

Department of Insurance and Financial Services
Office of General Counsel-Appeals Section
P.O. Box 30220
Lansing, MI 48909-7720
Courier/Delivery: 530 W. Allegan Street, 7^th Floor Lansing, MI 48933

Phone: 1-877-999-6442

Fax: 517-284-8838

Email: DIFS-HealthAppeal@michigan.gov

Online: https://difs.state.mi.us/Complaints/ExternalReview.aspx

You may also request a State Fair Hearing with the Michigan Office of Administrative Hearings and Rules (MOAHR). You may request this hearing only after receiving notice that UPHP upheld our previous decision. You have 120 days from the date of our decision to request a State Fair Hearing. Forms will be included in the appeal denial notice. You may also call UPHP Customer Service to get the form you need to ask for a state fair hearing. To appeal, please write to:

Michigan Department of Health and Human Services
Michigan Office of Administrative Hearings and Rules
P.O. Box 30763
Lansing, MI 48909

Phone: 1-800-648-3397
Fax: (517) 763-0146

If you need help with the appeal process, call UPHP Customer Service at 1-800-835-2556 (TTY: 711).