Appeals, Coverage Determinations, and Grievances
Your health and satisfaction are important to us. If you have a concern or problem as an Upper Peninsula Health Plan (UPHP) member there are three types of processes (organization determinations, appeals and grievances) to follow depending on the nature of the issue. The information below will help you determine the best way to proceed.
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 your 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:
Mail: Upper Peninsula Health Plan
Attn: Utilization Management
853 West Washington Street
Marquette, MI 49855
Note: Your Prepaid Inpatient Health Plan (PIHP) will make coverage decisions for behavioral health, intellectual/developmental disability, and substance use disorder services and supports. Contact your PIHP for more information. Please call NorthCare Network at 1-888-333-8030 (TTY: 711).
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 60 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. 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 Administrative Hearings System (MAHS) and/or a request 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 an External Appeal with the Medicare Independent Review Entity (IRE). You can also ask for an External Appeal with MAHS and/or 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)
Write: Upper Peninsula Health Plan
853 West Washington Street
Marquette, MI 49855
If you need help during the appeals process, you can call the MI Health Link Ombudsman at 1-888-746-6456. The MI Health Link Ombudsman is not connected with us or with any insurance company or health plan.
Note: Your Prepaid Inpatient Health Plan (PIHP) handles appeals about behavioral health, intellectual/developmental disability, and substance use disorder services and supports. Contact your PIHP for more information. Please call NorthCare Network at 1-888-333-8030.
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 CMS-1696. Click here to download a copy of the form (Clicking this link will take you away from UPHP’s website). You may call UPHP Customer Service with questions toll free at 1-877-349-9324 (TTY: 711), seven days a week from 8 a.m. to 9 p.m. Eastern time. The call is free.
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 Health Link Ombudsman program helps people enrolled in MI Health Link 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 8 a.m. to 5 p.m. Eastern time.
Website: www.mhlo.org (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.
Write: State Long Term Care Ombudsman15851 South US 27 Suite 73
Lansing, MI 48906
Website: http://mltcop.org/ (Clicking this link will take you away from UPHP’s website.)
Fax: 1-906-225-4516 Call: 1-877-349-9324 (TTY: 711), seven days a week from 8 a.m. to 9 p.m. Eastern time. The call is free. If we deny your request, you can appeal our decision. Simply complete the Request for Redetermination of Medicare Prescription Drug Denial form. More information about prescription grievances and appeals: UPHP MI Health Link Member Medicare Prescription Drug Coverage Grievance and Appeals
Page Last Updated: 09/26/2018
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