Member Complaints

GVHP wants you to be completely satisfied. If you are not, you have the right to voice your concerns. You can do this in a number of ways.

You can discuss your concerns directly with your GVHP Family Health Center. We encourage you to start there. GVHP Family Health Center staff are very concerned about your satisfaction. They would like the opportunity to correct any service issues. And, most questions and concerns can best be answered by your GVHP Family Health Center.

If you are unable to get the information you need or you are not satisfied with the answer, you can always call the GVHP Customer Service Team at 616-949-2410 or 800-335-1977.

The GVHP Customer Service Team will work with you. We will investigate your complaint. This could mean that we will call your GVHP Family Health Center or practitioner. We will review your Certificate of Coverage. We will look at our procedures and processes. We will get other information as needed. Our goal is to resolve all your complaints or concerns.

When we complete our investigation, we will contact you. You will also be given information on what has been found. We will help you understand how GVHP works. If you are dissatisfied with a decision, you have the right to file a grievance.

MEMBER GRIEVANCES/APPEALS

As a member of GVHP, you have the right to file a formal grievance/appeal. This grievance process is provided to you at no cost. You or a representative you have assigned in writing can request this process. Simply click on the link below or call the GVHP Customer Service Team at 616-949-2410 or 800-335-1977.

Click here for the Member Grievance Procedure.

Click here for the Member Grievance Form.

How does the grievance process work? A summary of the GVHP Grievance Process is presented below.

If a member’s request has been denied, he or she receives a written statement. This gives the reasons for this decision. A member or their authorized representative may wish to contest this decision. This is done through the grievance process. GVHP responds to member grievances. Grievances can be provided orally or in writing. A member or their authorized representative receives a grievance form. They also receive a copy of the GVHP grievance procedure. At the request of the member, services may be continued. If the denial is upheld the member may be responsible for payment of the services.

Members or their authorized representative do not have to submit a written response. Grievance requests remain open for 90 calendar days. This is from the date of notification of denial. This is also called the “point of discovery.”

GVHP sends a letter telling the member we have received his or her grievance request. The GVHP Customer Service Team investigates. The GVHP Customer Service team arranges the 1st level grievance hearing. The President of GVHP hears the 1st level grievance within 15 calendar days of the day you filed the grievance.

If the member is not satisfied with the response of the 1st level grievance, he or she, or the authorized representative may orally inform the GVHP Customer Service Team. A Customer Service Representative will arrange for the next appeal level (2nd level). The appeal may be heard without the member or their authorized representative present. The member may also choose to have someone represent him or her. The member or his or her representative may make the appeal in person. It may also be done by “technological methods”. This can be done by a telephone conference call. The appeal is heard by the GVHP-Grievance Committee. This committee is made up of GVHP Board members.

If the member or their authorized representative chooses not to attend or does not come to the 2nd level grievance hearing, the GVHP Grievance Committee reserves the right to hear the grievance and make a decision. GVHP will notify the member of the decision within two (2) business days.

The GVHP Grievance Committee hears the 2nd level appeal within another 15 calendar days of receipt of your request for a second level hearing. A response with the decision of the committee must be done within five (5) working days of a decision and not after the15 calendar day requirements. The GVHP Grievance Committee’s decision is the final decision of the Plan. If GVHP informs the member orally of the decision, a letter confirming it will be sent no later than two (2) business days after the oral notice.

The member or their authorized representative may appeal the GVHP Grievance Committee decision to the State of Michigan Office of Financial and Insurance Regulation. This should be done within 60 days of your denial. GVHP will provide the member or authorized representative with the appropriate form to request an external review with the Commissioner of the Office of Financial and Insurance Regulation. If a member requests an external review, he or she will be required to release any medical records required to be reviewed for the purpose of reaching a decision. The member can also inquire about the external review process by contacting:

Please note: The Commissioner of the Office of Financial and Insurance Regulation will not hear your grievance/appeal until you have exhausted the internal GVHP grievance process. The only exception is when GVHP did not complete their review within the required period of time.

The entire GVHP grievance/appeal process may not go over 30 calendar days. Or 40 calendar days with an extension (as requested by GVHP for purposes of receiving medical information). The grievance process includes the 1st and 2nd levels of appeal.

EXPEDITED GRIEVANCES

You, your authorized representative, or your physician may want to file an expedited grievance. An “expedited” grievance is one that must be resolved quickly. An urgent condition means you and your physician believe your need is serious or life-threatening. You and your physician believe you are not getting the care you need.

Always discuss your medical needs with your GVHP Family Health Center Practitioner. If you think your condition is urgent, tell him or her. Your GVHP Family Health Center Practitioner can help you understand your medical needs. He or she can discuss treatment options. You can explore options with your GVHP Family Health Center practitioner. If you are not satisfied with this information, you can file an expedited grievance. You may also file a grievance without talking to your GVHP Family Health Center Practitioner.

How does the process work? It begins when you, your authorized representative, or your physician calls the Medical Director. You may reach the Medical Director at 1-800-335-1977. Or you can call 1-616-949-2410 or 800-335-1977. The Medical Director will need your medical information. Once you or your authorized representative contacts GVHP you or your authorized representative may also contact the Office of Financial and Insurance Regulation to register an expedited grievance. This must be done within 10 days of the original denial.

After getting your request, GVHP has 72 hours to resolve a clinically urgent appeal. The 72-hour period begins when we get your request.

If GVHP makes the determination orally, GVHP shall provide a written confirmation of the determination to the member no later than two (2) business days after the oral determination.

If you are not satisfied with GVHP’s decision, within ten (10) days after receipt of a determination, you may request a determination of the matter by an independent review organization under the patients right to independent review act. GVHP will provide the member with the appropriate form to request an external review. If you request an external review, you will be required to release any medical records required to be reviewed for the purposes of reaching a decision. If you have any questions regarding this process you can also contact the Office of Financial and Insurance Regulation, at the address and phone number listed below:

For more information about this process, call your GVHP Customer Service Team at 616-949-2410 or 800-335-1977.