Rights and Protections

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Appeals and Grievance - Medicaid

McLaren Health Plan (MHP) wants you to be happy with the health care you receive. MHP has a process for you to voice your complaints about the health care you receive from our contracted doctors or services you receive from us.

Complaint/Grievance Procedure - Medicaid

For medical services, MHP, wants to hear your comments so that we can make our services better for our members. We want you to be able to receive answers to any questions that you have about MHP. We also want to provide you ways of reaching fair solutions to any problems that you may have with MHP. When you have any comments or concerns, please call Customer Service at (888) 327-0671.

You or your representative can file a grievance over the phone by calling Customer Service. We have staff ready and able to assist you in submitting your complaint/grievance. For standard grievances not related to dental, access to care or billing, MHP has thirty (30) calendar days to complete our investigation and resolution to your complaint/grievance. For Access to care complaints/grievances MHP will resolve your concern within 24 - 48 hours to ensure timely access to covered services. Billing complaints/grievances will be updated or resolved within 2 weeks of receipt. Dental related complaints/grievances should be directed to Delta Dental at 866-558-0280.

We have resources to assist you if you need interpreter services, document translation, auxiliary aids and services and TTY/TDD services, upon request and free of charge.

Member Appeal Procedure - Medicaid

If MHP has decided to deny, terminate, or reduce any covered service, in whole or in part, you can file an appeal. If you want to request an appeal with MHP’s Appeals Committee, you or your authorized representative must submit an appeal request in writing or orally within 60 calendar days of MHP’s resolution to your complaint/grievance or denial of services. If you submit your appeal request in writing, you can send your request along with any additional information to:

McLaren Health Plan
Attn: Member Appeals
G-3245 Beecher Road
Flint, Michigan 48532

Email: MHPAppeals@mclaren.org

Fax: (810) 600-7984

If you wish to have someone else act as your authorized representative to file your appeal, you will need to complete MHP's Authorized Representative Form, or you may call Customer Service at (888) 327-0671 for a copy to be mailed to you.

For Children’s Special Health Care Services (CSHCS) member appeals, MHP has ten (10) calendar days to complete the appeal process. For Non-CSHCS member appeals, MHP has thirty (30) calendar days to complete the appeals process. You will receive notification in writing within three (3) calendar days of the determination of the appeal. You may also request copies of information relevant to your appeal, free of charge, by contacting Customer Service at 888-327-0671.

If, after your appeal, we continue to deny payment, coverage, or the service requested, or you do not receive a timely decision, you can ask for an external appeal. You must do this within one hundred twenty-seven (127) days of receiving MHP's appeal decision. MHP will provide the form required to file an external appeal. These requests should be mailed to:

Department of Insurance and Financial Services
Office of Research, Rules, and Appeals – Appeals Section
P.O. Box 30220
Lansing, Michigan 48909-7720

Or call: (877) 999-6442 (toll free)

Or fax: (517) 284-8838

Or submit online at: https://difs.state.mi.us/complaints/externalreview.aspx

Expedited Complaint/Grievance or Appeal - Medicaid

If you (or another person, including a physician, who is authorized in writing to act on your behalf) believe that due to your medical status, resolution of your complaint/grievance and/or appeal within MHP’s normal time frames would seriously jeopardize your life or health or ability to regain maximum function, the expedited complaint/grievance or appeals process may be utilized.

Expedited Complaint/Grievance or Appeals should be made by telephone by calling MHP at (888) 327-0671.

MHP will make a determination concerning your expedited complaint/grievance or appeal and communicate that to you and your physician as expeditiously as the medical condition requires, but not later than seventy-two (72) hours after receipt. You and your physician will be provided with written confirmation of this determination within two (2) calendar days, following the verbal determination.

Complaint and Appeals Process - McLaren Health Plan Community - Individual (On and Off Exchange)

McLaren Health Plan (MHP) Community wants you to be happy with the health care you receive. MHP Community has a process for you to voice your complaints about the health care you receive from our contracted doctors or services you receive from us.

At MHP Community, we want to hear your comments so that we can make our services better for our members. We want you to be able to receive answers to any questions that you have about MHP Community . We also want to provide you with ways of reaching fair solutions to any problems that you may have with MHP Community. When you have any comments or concerns, please call Customer Service at (888) 327‑0671 (TTY: 711).

You or your representative can file a grievance over the phone by calling Customer Service. We have staff ready and able to assist you in submitting your complaint/grievance. For standard grievances not related to access to care or billing, MHP has thirty (30) calendar days to complete our investigation and resolution to your complaint/grievance. For Access to care complaints/grievances MHP will resolve your concern within 24 - 48 hours to ensure timely access to covered services. Billing complaints/grievances will be updated or resolved within 2 weeks of receipt.

We have resources to assist you if you need interpreter services, document translation, auxiliary aids and services and TTY/TDD services, upon request and free of charge.

Member Appeal Procedure - McLaren Health Plan Community - Individual (On and Off Exchange)

If MHP Community has decided to deny, terminate, or reduce any covered service, in whole or in part, you can file an appeal. If you want to request an appeal with MHP Community's Appeals Committee, you or your authorized representative must send an appeal request in writing within 180 calendar days of MHP Community's resolution to your complaint/grievance or denial of services. You can send your appeal request along with any additional information to:

McLaren Health Plan Community
Attn: Member Appeals
G-3245 Beecher Road
Flint, Michigan 48532
Email: MHPAppeals@mclaren.org
Fax: 810-600-7984

If you wish to have someone else act as your authorized representative to file your appeal, you will need to complete MHP's Authorized Representative Form, or you may call Customer Service at (888) 327‑0671 (TTY: 711) for a copy to be mailed to you.

MHP Community has thirty (30) calendar days to complete the internal appeal process for a pre-service appeal request, and sixty (60) days for post-service appeal request. You will receive notification in writing within three (3) calendar days of the determination of the appeal. You may also request copies of information relevant to your appeal, free of charge, by contacting Customer Service at (888) 327‑0671 (TTY: 711).

If, after your appeal, we continue to deny payment, coverage, or the service requested, or you do not receive a timely decision, you can ask for an external appeal. You must do this within sixty (60) days of receiving MHP's appeal decision. MHP will provide the form required to file an external appeal. These requests should be mailed to:

Department of Insurance and Financial Services
Office of Research, Rules, and Appeals – Appeals Section
P.O. Box 30220
Lansing, Michigan 48909-7720

Or call: (877) 999-6442 (toll free)

Or fax: (517) 284-8838

Or submit online at: https://difs.state.mi.us/complaints/externalreview.aspx

Expedited Complaint/Grievance or Appeal - McLaren Health Plan Community - Individual (On and Off Exchange)

If you (or another person, including a physician, who is authorized in writing to act on your behalf) believe that due to your medical status, resolution of your complaint/grievance and/or appeal within MHP Community's normal time frames would seriously jeopardize your life or health or ability to regain maximum function, the expedited complaint/grievance or appeals process may be utilized.

Expedited Complaint/Grievance or Appeals should be made by telephone by calling MHP at (888) 327‑0671 (TTY: 711).

MHP Community will make a determination concerning your expedited complaint/grievance or appeal and communicate that to you and your physician as expeditiously as the medical condition requires, but not later than seventy-two (72) hours after receipt. You and your physician will be provided with written confirmation of this determination within two (2) calendar days, following the verbal determination.

Clinical Practice Guidelines

McLaren Health Plan uses Clinical Practice Guidelines, which are standards of care for doctors to follow, to aide doctors and members to make decisions about appropriate health care.

McLaren Health Plan's Chief Medical Officer (CMO) oversees the development of the guidelines and the Quality, Safety and Service Improvement Committee (QSSIC) has final approval responsibility.

McLaren Health Plan's disease management programs are based on the Clinical Practice Guidelines. If you have any questions about McLaren Health Plan's Clinical Practice Guidelines, or if you would like a printed copy of any guideline, please call Customer Service at 888-327‑0671.

Last Updated 01/09/2018

Please Note: There may be links on the McLaren Health Advantage website that take you to non-McLaren Health Advantage information. By clicking these links you will be leaving the McLaren Advantage web pages.

Fraud, Waste and Abuse

McLaren Health Plan (MHP) is committed to preventing health care fraud, waste, and abuse, as well as complying with applicable state and federal laws governing fraud and abuse.

Examples of fraud & abuse by a member include:

  • Altering or forging a prescription
  • Altering medical records
  • Changing or forging referral forms
  • Allowing someone else to use their MHP member ID card to obtain health care services

Examples of fraud & abuse by a provider include:

  • Falsifying their credentials
  • Billing for services not performed
  • Billing more than once for same services
  • Upcoding and unbundling procedure codes
  • Over-utilization, performing inappropriate/unnecessary services
  • Under-utilization, not ordering services that are medically necessary
  • Collusion among providers

Examples of fraud and abuse by a MHP employee include:

  • Altering provider contracts or forging signatures
  • Collusion with providers or members
  • Intentionally denying services or benefits that are normally covered
  • Inappropriate incentive plans for providers
  • Embezzlement or theft

The Deficit Reduction Act of 2005 requires information about both the federal False Claims Act and other laws associated with:

  • Fraud, Waste, & Abuse
  • Whistleblower Protection

Federal law prohibits an employer from discriminating against an employee in the terms and conditions of his/her employment because the employee initiated or otherwise assisted in a false claims action.

To report a possible violation, (you may remain anonymous), in writing to:

McLaren Health Plan
Attn: Compliance Officer
G-3245 Beecher Road, Suite 200
Flint, MI 48532

By email at MHPCompliance@mclaren.org,

Or by calling the MHP Compliance Hotline: (866) 866-2135.

To report Medicaid Fraud, Waste, & Abuse (you may remain anonymous), in writing to:

Michigan Department of Health and Human Services
Office of Inspector General
P.O. Box 30062
Lansing, MI 48909
By telephone at: (855) MI-FRAUD (643-7283)

Member Rights and Responsibilities

McLaren Health Plan Members have the right to:

  • Confidentiality
  • Be treated with respect and recognition of their dignity and the right to privacy, including to be free from restraint and seclusion
  • Have access to a primary care provider or provider designee 24 hours a day, 365 days a year for urgent care
  • Receive culturally and linguistically appropriate services
  • The right to receive covered benefits consistent with your contract and State and Federal regulations
  • Obtain a current provider directory of participating providers and access to a choice of specialists within the network who are experienced in treatment of chronic disabilities, with a referral
  • Obtain OB-GYN and pediatric services from network providers without a referral request
  • Continue receiving services from a provider who has been terminated from the Plan’s network, through the episode of care, as long as it remains medically necessary to continue treatment with this provider, including female members who are pregnant have the right to continue coverage from a terminated provider that extends to the postpartum evaluation of the member, up to 6 weeks after delivery
  • Have no "gag rules" from the Plan. Doctors are free to discuss all medical treatment options, even if they are not covered services
  • Participate in decision-making regarding his/her health care, including the right to refuse treatment, to obtain a second opinion, and express preferences about treatment options
  • Receive a copy of their medical record upon request, and request those to be amended or corrected
  • Know how the Plan pays its doctors, allowing Members to know if there are financial incentives or disincentives tied to medical decisions; and the right to be provided with a telephone number and address to obtain additional information about compensation methods, if desired
  • Voice complaints or appeals about McLaren Health Plan, the care provided or a decision to deny or limit coverage, including that a member or provider cannot be penalized for filing a complaint or appeal in compliance with federal and state laws
  • Receive information about McLaren Health Plan, including the services provided, the practitioners and providers, and the members’ rights and responsibilities
  • Make recommendations regarding McLaren Health Plan’s member’s rights and responsibilities
  • Be free from other discrimination prohibited by State and Federal regulations
  • Having the member’s medical record be kept confidential by McLaren Health Plan and the PCP

McLaren Health Plan Members have the responsibility to:

  • Schedule appointments in advance and be on time; and cancel an appointment with the doctor’s office as soon as possible
  • Use the hospital emergency room only for acute or emergency care, not for routine care - this means following the protocol and using the emergency room only when medically necessary, and contacting the PCP prior to a visit to the emergency room
  • Become a partner with the PCP in planning individual health care and completing treatments, including supplying the information (to the extent possible), to practitioners, providers, and the health plan that is needed to deliver the services needed
  • Follow plans and instructions for care that the member has agreed on with all their treating health care providers and practitioners
  • Understanding their health problems and participate in developing treatment goals to the degree possible
  • Notify McLaren Health Plan’s Customer Service immediately for any change in address or telephone number
  • Allow McLaren Health Plan to assist with health care and services to which a member is entitled and of notifying the Plan of any problem related to health care, benefits, etc.
  • Forward suggestions to McLaren Health Plan in writing or contacting Customer Service for assistance
  • Carry the McLaren Health Plan Member ID card at all times

(April 2019)

Privacy Policy

Surprise Medical Billing – Your Rights and Protections

Utilization Management

Criteria Availability

McLaren Health Plan's Utilization Management Program is structured to deliver fair, impartial and consistent decisions regarding health services. There are industry standard written criteria that are used when determining if health services are medically necessity. The criteria used in the decision making are available to you upon request by calling the Medical Management Department at (888) 327-0671 or (810) 733-9722.

Behavioral Health services for Medicaid members are not subject to any medical necessity review at this time.

Incentives

Utilization decision-making is based only on appropriateness of care and service and existence of coverage. We do not specifically reward practitioners or other individuals for issuing denials of coverage, service or care. Nor are there financial incentives for utilization decision makers to encourage decisions that result in under utilization.