Michigan's Auto Insurance Utilization Review
Under Michigan's auto insurance law, medical care provided to a person injured in an auto accident must meet requirements for medical appropriateness. Auto insurers must establish utilization review programs to make these determinations, which can be appealed by health care providers to the Michigan Department of Insurance and Financial Services (DIFS) Utilization Review section. The rules governing Michigan's Auto Insurance Utilization Review took effect December 18, 2020.
Please see DIFS' Frequently Asked Questions regarding Utilization Review.
Notice for Injured Persons: If you receive a notice related to utilization review appeals or determinations, that means that an appeal has been submitted by your health care provider. You are not required to take action. If you have questions or need assistance, please contact DIFS at 833-ASK-DIFS (833-275-3437) or email@example.com.
Health Care Provider Appeals
If a health care provider disagrees with a utilization review determination made by an auto insurer or the Michigan Catastrophic Claims Association (MCCA) about whether medical care provided to an injured person meets the standards under Michigan's auto insurance law, the health care provider may appeal within 90 days of the date of the disputed determination from the insurer. DIFS will not accept appeal requests that are untimely. Health care providers must file their appeal by completing the required Auto Insurance Utilization Review Provider Appeal Request (FIS 2356) form. The form must be submitted to DIFS by email at DIFS-URAppeals@michigan.gov or faxed to 517-763-0305.
An auto insurer or the MCCA may file a reply to the health care provider's appeal to DIFS no later than 21 days after the date of DIFS' notice of the appeal to the insurer or the MCCA. A reply from the insurer or the MCCA to an appeal must be submitted using the Auto Insurance Utilization Review Insurer Reply to Provider Appeal (FIS 2361) form. The form must be submitted to DIFS by email at DIFS-URAppeals@michigan.gov or faxed to 517-763-0305.
DIFS will issue an order resolving the appeal to both the health care provider and the insurer or the MCCA. If DIFS requires additional time to complete the decision, written notification of extension will be provided to the health care provider and the insurer or the MCCA.
For more information, please see The Health Care Provider's Guide to Michigan's Auto Insurance Utilization Review Appeal Process.
Note: DIFS' decisions are based on documentation provided by both parties. All documentation relevant to the appeal must be provided with the Auto Insurance Utilization Review Provider Appeal Request (FIS 2356) form and the Auto Insurance Utilization Review Insurer Reply to Provider Appeal (FIS 2361) form.
Auto Insurer Certification
Auto insurers doing business in Michigan must have in place a certified utilization review program that complies with the utilization review administrative rules. To submit an new application for certification, the insurer must complete the DIFS' Application for Unconditional Certification of Auto Insurance Utilization Review Program (FIS 2362) and submit the application to DIFS by email at DIFS-URCertification@michigan.gov or faxed to 517-763-0305. Following review of the insurer's application, DIFS will provide a notice of either unconditional or conditional approval of the insurer's utilization review program. The notice will provide instructions on certification renewals.
Utilization Review Annual Report
On an annual basis, auto insurers must submit the Auto Insurance Utilization Review Insurer Annual Report (FIS 2358) to DIFS no later than March 31 of each year. The form will be used to provide DIFS any information regarding material changes to the insurer's utilization review program, as well as the preceding year's utilization review activities. The form must be submitted to DIFS by email at DIFS-UR@michigan.gov or faxed to 517-763-0305.
For insurers and health care providers:
Phone: 833-ASK-DIFS (833-275-3437)