Coverage Decisions, Appeals & Complaints

When a coverage decision involves your medical care or long term supports and services, it is called an “organization determination”. An organization determination is the initial decision we make about your benefits and coverage or about the amount we will pay for your medical services that you are requesting. We are making an organization determination anytime we decide what is covered for you and how much we will pay. If you are having problems getting medical care, a service you requested, or payment (including the amount you have already paid) for medical care or services you have already received, then you can resolve the problem through an organization determination. If your health requires a quick response, you should ask us to make a ”fast coverage decision.” If we say no to a fast coverage decision, you can file a “fast complaint” about our decision to take extra days. If we do not give you our answer within the coverage decision deadline, you have the right to appeal.

To request coverage for the medical care or other supports or long term supports and services you want, you, your doctor, or your representative may call us at 906-225-7774 or toll-free at 1-877-349-9324 (TTY: 711), or you can complete and send the UPHP Coverage Determination Request Form to:

Fax: 906-225-9269
OR
Mail: Upper Peninsula Health Plan
Attn: Utilization Management
853 West Washington Street
Marquette, MI 49855

UPHP uses written criteria to assist with making medical necessity decisions. Our  criteria is available for you to access and view.

If we make a coverage decision and you are not satisfied with our decision or part of our decision, you, your doctor, or your representative can ”appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. If your health requires a quick response, you must ask for a ”fast appeal.”   

If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. While we can accept an appeal request without the form, we cannot begin or complete our review until we receive it.

You must make your appeal request within 65 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

When our plan is reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request. When we have completed the review we will give you our decision in writing.

For Medicare covered services, if we say no to all or part of your Level 1 Appeal or do not provide an answer within the deadline, your appeal will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our Plan called the Medicare Independent Review Entity (IRE). If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal. 

For Medicaid covered services, you can file an External Appeal yourself with the Michigan Office of Administrative Hearings and Rules (MOAHR) and/or ask for an External Review with the Michigan Department of Insurance and Financial Services (DIFS).

If your problem is about a service or item that could be covered by both Medicare and Michigan Medicaid, you will automatically get a Level 2 appeal with the Medicare IRE. You can also ask for an External Appeal with MOAHR and/or an External Review with DIFS. These additional levels are explained in your Member Handbook/Evidence of Coverage.

To file an appeal you, your doctor, or your representative may:

Call: Toll-free 1-877-349-9324 (TTY: 711)
Fax: 906-225-7720
Write: Upper Peninsula Health Plan
Attn: Clinical Services – Appeals or Pharmacy
853 W. Washington Street
Marquette, MI 49855

If you need help during the appeals process, you can call the MI Community, Home, and Health Ombudsman at 1-888-746-6456. The MI Community, Home, and Health Ombudsman is not connected with us or with any insurance company or health plan.

To appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on your behalf, complete and submit an Appointment of Representative form. You may call UPHP Customer Service with questions toll free at 1-877-349-9324 (TTY: 711), Monday through Friday from 8 a.m. to 9 p.m. Eastern time.  The call is free.

If you have a complaint about quality of care, waiting times, or the customer service you receive, you or your representative may call 1-877-349-9324 (TTY: 711). We will try to resolve your complaint over the phone. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.  You can make the complaint at any time unless it’s about a Medicare Part D drug. If the complaint is about a Medicare Part D drug, you must make it within 60 calendar days after you had the problem you want to complain about.

Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we decide to take extra days, we will tell you in writing.

You can mail or fax your written grievances to:

Upper Peninsula Health Plan
853 West Washington Street
Marquette, MI 49855
Fax: 1-906-225-7690

You may also file a complaint by phone at 1-800-MEDICARE or electronically by using the
Medicare Complaint Form (Clicking on this link will take you away from the Upper Peninsula Health Plan’s website).

More information on the grievance process can be found in Chapter 9 of the UPHP MI Coordinated Health Member Handbook.

You can contact the Office of the Medicare Ombudsman (OMO) for help with a complaint, grievance, or information request.  To learn more, visit the Ombudsman website (Clicking this link will take you away from UPHP’s website.

The MI Community, Home, and Health Ombudsman program helps people enrolled in MI Coordinated Health with service or billing problems. They can help you file a complaint or an appeal with our plan.
Call: toll-free 1-888-746-6456 (TTY 711) Monday through Friday between the hours of 9 a.m. to 5 p.m. Eastern time.
Email: MI-CHHO@meji.org
Website: <enter new website address>(Clicking this link will take you away from UPHP’s website.)

State Long Term Care Ombudsman
The State Long Term Care Ombudsman program helps people learn about nursing homes and other long term care settings. It also helps solve problems between these settings and residents or their families.

Call: 1-866-485-9393
Write: State Long Term Care Ombudsman 15851 South US 27 Suite 73
Lansing, MI 48906
Email: SLTCO@michigan.gov
Website: http://mltcop.org/ (Clicking this link will take you away from UPHP’s website.)

Your benefits as a member of our plan include coverage for many drugs. Most of these are Medicare Part D drugs. There are a few drugs that Medicare Part D doesn’t cover that Michigan Medicaid may cover.

To be covered, the drug must be used for a medically accepted indication. That means the drug is approved by the Food and Drug Administration (FDA) or supported by certain medical references.

Here are examples of coverage decisions you ask us to make about your Medicare Part D drugs:

• You ask us to make an exception, including asking us to:
• cover a Medicare Part D drug that isn’t on our plan’s Drug List or
• set aside a restriction on our coverage for a drug (such as limits on the amount you can get)
• You ask us if a drug is covered for you (such as when your drug is on our plan’s Drug List but we must approve it for you before we cover it)
• You ask us to pay for a drug you already bought. This is asking for a coverage decision about payment. Refer to Chapter 7 of the UPHP MI Coordinated Health Member Handbook.

NOTE: If your pharmacy tells you that your prescription can’t be filled as written, the pharmacy gives you a written notice explaining how to contact us to ask for a coverage decision.

You can also ask us to make a coverage decision about the drugs covered under your Medicaid Benefit.

If you disagree with a coverage decision we made, you can appeal our decision.

Find out what drugs we cover, our rules for covering certain drugs, and how to ask us for a drug coverage decision or appeal.