Physicians Health Plan of South Michigan will be transitioning its membership to Priority Health, subject to regulatory approval.

Physicians Health Plan of South Michigan Named One of the Best in The Nation by U.S.News & World Report/NCQA “America’s Best Health Plans” 2006

For the second year in a row, Physicians Health Plan of South Michigan has been named one of the best commercial health plans in the nation by the U.S.News & World Report/NCQA "America's Best Health Plan"* 2006.

iSave

PHPSM is proud to offer you iSave - our six new high deductible health plans (HDHP's). iSave features low premiums and first dollar coverage for preventive care. iSave helps you get your healthcare spending back on track. For more information, please click the title link above.

Leapfrog

Leapfrog is a program to provide information about health care safety, quality and customer value. Click the title above for more details.

Physicians Health Plan of South Michigan's Members Area

Member Appeal Process

If you are not satisfied with a PHPSM decision regarding the payment or denial of a medical claim, you may file a grievance (appeal). An appeal is a request to PHPSM to reconsider the decision they made.

An appeal must be in writing. To begin the appeal process, you may complete a Appeal Request Form to explaining your dissatisfaction. On this form, you may request that another person represent you. Once completed, it should be sent to our Customer Service Department.

The PHPSM Appeals Team will then investigate your issue. If the issue cannot be quickly resolved to your satisfaction, we will invite you to meet with the Grievance Committee. You and/or your personal representative may meet with the committee in person or by telephone. The committee, made up of people not involved in the original decision, will be glad to hear your testimony and review any additional information at that time. A final decision will be made with 30 calendar days of PHPSM’s receipt of your written appeal.

The final decision will be sent to you in writing. If you are still unhappy with our decision, you may request a review by the Office of Financial and Insurance Services. You may write to them at PO Box 30220, Lansing, MI 48909, call them at 877-999-6442 or access their website at www.michigan.gov/ofis.

As part of our continuous quality improvement, we review the reasons why members request an appeal. For the year 2003, the top two categories were “not a covered benefit” and “services provided by a non-participating provider.”

Non-participating claims were appealed most frequently. These appeals were the result of members seeking services outside the network.

Items considered “not a covered benefit” include, but are not limited to, copays required for services, experimental or cosmetic procedures; coverage requested for items that do not meet the definition of Durable Medical Equipment; and dental services or contact. For this category of appeals, members appealed the copay application the most, followed by a denial for either an experimental/unproven procedure or a cosmetic procedure.

Our goal is to provide great service to you. The appeals process is here to ensure that your concerns and questions are reviewed in detail. If you question whether a provider is participating or if a service is a covered benefit, please call Customer Service. We are here for you, available from 8 a.m. to 5 p.m. Monday through Friday at 787-6865 or 1-800-394-7569 to answer these questions.