Health Coverage Grievances and Appeals
INTERNAL GRIEVANCE PROCESS:
Under Michigan laws, each health carrier must establish an internal formal grievance process. This process gives you or your authorized representative an avenue to seek resolution when you have received an adverse determination. An adverse determination means that an admission, availability of care, continued stay, or other health care service has been reviewed and has been denied, reduced, or terminated. Failure to respond in a timely manner to a request for a determination also constitutes an adverse determination.
Your health carrier is required to make sure all steps in the internal grievance process are completed within 30 calendar days after the written request has been submitted if the grievance concerns a service that has not yet been received, or 60 calendar days if it concerns a service has been received. This does not include the time you take to decide to go from one step in the process to the next step in the process. The health carrier may take up to an additional 10 business days to obtain necessary medical information.
BEGINNING THE INTERNAL GRIEVANCE PROCESS:
The first step in the internal grievance process is to provide your health carrier with a written grievance, which consists of your written statements regarding the facts of the issue and your position. Your health carrier is required to provide you with the address to submit the written grievance and any special forms, as well as information on how to begin the internal grievance process. After you submit the written grievance to your health carrier, your health carrier is required to notify you of its determination in writing and to advise you of your right to the next step(s) in the grievance process if you disagree with the determination, and your right to request an external review.
FURTHER STEPS IN THE INTERNAL GRIEVANCE PROCESS:
The next step in the internal grievance process may give you the right to appear before a designated person or designated committee at the managerial level to complete the grievance (this will depend on the number of steps in the internal grievance process-but this step must be offered). After this step, the health carrier is required to notify you of its determination in writing and to advise you of the external review process and the right to request an external review with the Department of Insurance and Financial Services (DIFS) under the Patient's Right to Independent Review Act; or, other external review processes that may be available to the patient.
PATIENT'S RIGHT TO INDEPENDENT REVIEW ACT (PRIRA):
The Patient's Right to Independent Review Act (PRIRA) is a Michigan law that provides patients with the right to request an appeal of an adverse decision made by a health carrier regarding a denial, reduction, or termination of health care services. You are only eligible for the external review process if you have exhausted your health carrier’s internal grievance process, or if it failed to complete the internal process under the time dictated by law, or if a carrier waives its internal grievance process or waives the requirement that a patient exhaust the process before seeking external review. The PRIRA external review process does not apply to a medical provider's complaint concerning claims payment, handling, or reimbursement for health care services.
REQUIRED INFORMATION FOR PRIRA EXTERNAL REVIEW:
To request an external review under the PRIRA, you or your authorized representative must complete the Health Care Request for External Review Form. The request should also include a copy of the final adverse determination from the health carrier along with information and documentation to support your position. The request must be submitted within 120 days after you have received your health carrier's final adverse determination.
APPOINTMENT OF AUTHORIZED REPRESENTATIVE:
You may authorize in writing any person, such as a doctor, attorney, parent or spouse, to represent you in the internal grievance process and/or the PRIRA external review process. In the PRIRA external review process, this person is called an authorized representative. The Health Care Request for External Review Form provides space to authorize a representative, who will be DIFS' sole contact in the PRIRA external review process.
ATTORNEYS IN PRIRA EXTERNAL REVIEW PROCESS:
You or your authorized representative are not required to have an attorney represent you through the PRIRA external review process.
PRELIMINIARY REVIEW OF REQUEST FOR PRIRA EXTERNAL REVIEW:
DIFS has 5 business days to conduct a preliminary review to determine if you are eligible for the PRIRA external review process. DIFS notifies your health carrier of the request and obtains pertinent information to help decide if the patient and health care service is eligible for a PRIRA external review. The request must meet these requirements:
- The issue must involve an adverse determination.
- The coverage involved must be subject to the Patient's Right to Independent Review Act.
- The patient must have been a covered person at the time the health care service was provided or requested.
- The health care service in question must reasonably appear to be a covered service under the contract or policy.
- The covered person must have exhausted the internal grievance process of the health carrier.
Furthermore, if the request for external review involves issues of experimental or investigational service or treatment, DIFS has 5 business days to complete a preliminary review to determine the following:
- Whether the person requesting the procedure is covered by a health benefit plan;
- Whether the procedure would be covered if it were not determined to be experimental, or is not explicitly excluded in the benefit plan;
- Whether the patient's authorized treating provider has certified that standard care has been ineffective, would be inappropriate, or that there is no standard care more beneficial than the experimental care;
- Whether the patient's authorized treating provider has certified that the experimental care is likely to be more beneficial than standard care or that scientifically valid studies show that to be the case;
- Whether the patient has exhausted the health carrier's internal grievance program, unless it is not necessary to do so under the act; and
- Whether the patient has submitted all required information to DIFS.
DIFS will consider the following: (1) whether the requested health care service has been approved by the US Food and Drug Administration (FDA), if applicable; or (2) if medical or scientific evidence demonstrates that the expected benefits of the requested service are more likely to be more beneficial to the patient than those of standard health care services, and would not present substantially more risk (risk-reward determination).
DIFS will notify you or your authorized representative in writing if the request for an external review is accepted or not accepted. Occasionally requests are determined to be incomplete, in which case you will be asked to provide the information needed to make the request complete. If the request is not accepted, DIFS will explain the reason why the request does not qualify for an external review under the PRIRA.
If your request is accepted and involves only contractual provisions of the contract or policy, the review is conducted by the Director of DIFS. If your request is accepted and involves issues of medical necessity or clinical review criteria, it is referred to an independent review organization (IRO).
INDEPENDENT REVIEW ORGANIZATION (IRO):
An IRO is an independent entity that has a contract with DIFS to conduct independent medical reviews under the PRIRA and make a recommendation to the Director. The IRO uses medical professionals with expertise in the health care service at issue in the review.
INVESTIGATION AND OBTAINING THE PATIENT'S MEDICAL RECORDS:
DIFS staff will not investigate, contact medical sources, or seek out information to support your position. It is your responsibility to provide the pertinent documents such as bills, explanations of benefits, medical records, correspondence, statements from doctors, and research material to support your position. If the issue in the review is referred to an IRO, the health carrier is required to provide the IRO with the medical records and other documents it used to make its adverse determination. The IRO will use this information to make its recommendation.
If the PRIRA external review does not require review by an IRO, the law requires the Director to issue a decision within 14 calendar days after the request is accepted for review. If the review requires referral to an IRO, the IRO is required to provide DIFS with its recommendation within 14 calendar days after it is assigned the review, and the Director must issue a decision within 7 business days after receiving the recommendation of the IRO.
RIGHT TO APPEAL DIRECTOR'S DECISION:
If you, or the health carrier disagree with the Director's decision, either has the right to appeal to circuit court in the county where the covered person resides, or in Ingham County, within 60 days from the date of the decision. If the decision overturns the health carrier's determination and the health carrier appeals to circuit court, DIFS will not represent you.
PRIRA EXPEDITED EXTERNAL REVIEW:
If you have a medical condition for which the timeframe for completion of the PRIRA external review would seriously jeopardize your life or health or your ability to regain maximum function, you may request an expedited external review. With issues involving an experimental or investigational service or treatment DIFS may consider whether the FDA has approved the procedure and conduct the risk-reward determination described above when deciding whether to allow an expedited external review. A PRIRA expedited external review is completed within 72 hours after your request (which DIFS prefers in writing) has been accepted for expedited external review.
To qualify for a PRIRA expedited external review, you must have your physician verify, orally or in writing, that the time frame for a non-expedited PRIRA external review would seriously jeopardize your life or health. A PRIRA expedited external review is only granted when the issue involves health care services that have not already been provided to the patient and the issue involves medical necessity of a serious medical condition.
The same form is used to request an expedited external and non-expedited review under the Patient's Right to Independent Review Act: Health Care Request for External Review Form.