The providers grievance policy
defines the process to be used by HealthPlus of Michigan for resolving
administrative complaints by, and disputes with, participating providers under
their provider agreements.
When a provider has a
concern, every effort will be made to resolve the issue informally. In the
event the issue cannot be resolved informally, the provider may request it be
handled according to the formal grievance policy. The Provider Service
Department will be the liaison between the providers and the health plan and
will provide the information regarding the formal process.
If a provider feels
aggrieved by a policy, decision, or procedure of HPM, he/she shall follow the
grievance procedure set forth below:
An aggrieved party must first send a written statement outlining the nature and
extent of the problem. The parties will meet within 45 days to discuss the
problem with the appropriate provider and HPM administrator. It is recognized that
many problems may be solved this way and a formal grievance may thereby be
If the meeting does not resolve the situation, then the responding party shall,
within five days, send a written response to the original written grievance.
Upon receipt of the notice,
a tribunal shall be formed composed of one representative appointed by HPM, one
representative appointed by clinic, and a third representative, who shall be
chairperson, who shall be selected by the two appointees (hereinafter referred
to as the "Tribunal"). This Tribunal shall conduct a hearing upon the
merits of the dispute within 30 working days of receipt of the notice, unless
the parties agree to a longer time. Within five working days from the
termination of the hearing, the Tribunal shall issue a decision in writing to
all parties involved in the dispute. All procedures surrounding said Tribunal
function shall be determined by said Tribunal, unless inconsistent with this
paragraph. Each party shall bear the cost of the representative it appointed
plus one-half of the expenses of the neutral representatives and other
If any party declines to accept that decision, that party has seven days in
which to file a formal written appeal of that decision to both boards of HPM
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