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Alliance Grievance Process
Purpose
To provide a mechanism by which any Alliance Health and Life Insurance Company (Alliance)
enrollee or their representative (with the appropriate authorization) may seek resolution to those
situations where the enrollee is dissatisfied or feels aggrieved by the services, benefits, and/or
policies and procedures of Health Alliance Plan or its providers.
Summary of the Grievance Process
The Grievance Process acknowledges the enrollee’s right to continue to voice a dissatisfaction
through a two-level decision-making process within Alliance. Enrollees or their representative
(with the appropriate authorization) who wish to initiate the grievance process, must submit their
request in writing to the Vice President of Client Services, 2850 W. Grand Boulevard, Detroit, MI
48202, within two (2) years from the date of discovery or date of the initial determination, i.e.,
denial of service/referral, rejection of claims by Alliance, etc. The enrollee should also include any
additional information; i.e., medical evaluation report, medical records or other pertinent
information they feel will further support the request. The Client Services Grievance Section will
send the enrollee or their representative an acknowledgment letter confirming Alliance’s receipt
and acceptance of the request to initiate the grievance process.
Alliance’s Grievance Process allows for a final determination (which includes both levels) to be
made within thirty (30) calendar days for both pre-service appeals (a request to change an adverse
determination for care that has not been received) and for post-service appeals (a request to
change an adverse determination for care that has already been received). If an enrollee approves
our request for an extension of this time frame, Alliance may be allowed up to ten (10) additional
days for review if we have not received requested information from a health care facility or health
professional required for the review. If Alliance exceeds the allowable time frame, enrollees may
proceed directly to the state and exercise their right for external review. Also, based on Section
502 (a) of the Employment Retirement Income Security Act (ERISA) of 1974, after exhausting both
levels of Alliance’s internal grievance process, an enrollee has the right to bring civil action based
on an adverse benefit determination. Additionally, upon your written request, you are entitled to
reasonable access to copies of documents, records and other information relevant to your
grievance that is permitted by law and according to ERISA.
A 72-hour Expedited Grievance Process is also available when medically indicated, (a medical
determination that the routine time frames for the internal grievance review would seriously
jeopardize the life or health of an enrollee or would jeopardize the enrollee’s ability to regain
maximum function, as substantiated by a doctor either orally or in writing). The eligibility of an
expedited grievance will be determined by Alliance based on the established criteria.