Health Coverage Grievances and Appeals
Internal Grievance Process
Michigan law requires all health carriers to establish an internal 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 complete the internal grievance process within 30 calendar days if the service has not yet been received or 60 calendar days if it concerns a service that has already been received. This does not include the time you take to decide to proceed to the next step in the process. The health carrier may take up to an additional 10 business days to obtain necessary medical information from your provider.
The first step in the internal grievance process is to provide your health carrier with a written grievance, which consists of your written statement 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 advise you of the next step(s) in the grievance process.
Some health carriers conduct a two-step internal grievance process and give you the right to appear before a designated person or designated committee at the managerial level. Otherwise, the managerial level conference is completed during the first step of the internal grievance process. If you disagree with the health carrier’s final adverse determination, you have 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. Other external review processes may be available to you, depending on the type of plan you have.
Patient’s Right to Independent Review Act (PRIRA)
PRIRA is a Michigan law that provides patients with the right to request an external review of a final adverse determination. You are only eligible for an external review under PRIRA if you have exhausted your health carrier’s internal grievance process, if your carrier failed to complete the process under the time dictated by law, or if your carrier waived its internal grievance process.
The PRIRA external review process does not apply to a medical provider's complaint concerning claims payment, handling, or reimbursement for health care services. However, a provider may be appointed as the patient’s authorized representative (see below). Providers experiencing problems with receiving timely payment for submitted claims without any errors or other issues should review the clean claims process.
Required information for PRIRA external review
To request an external review under PRIRA, you or your authorized representative must submit a Health Care - Request for External Review online or with the paper 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 127 days after you received your health carrier's final adverse determination.
If your external review request involves issues of experimental or investigational services or treatment, you must also obtain a certification from your treating provider using the Treating Provider Certification for Experimental/Investigational Denials form. This form should be submitted with your request for an external review. Requests involving experimental or investigational services or treatment that do not include the form will be deemed incomplete until the treating provider certification is received by DIFS.
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 the PRIRA external review process
You or your authorized representative are not required to have an attorney represent you through the PRIRA external review process.
Preliminary 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 request is eligible for a PRIRA external review. The request must meet these requirements:
- The issue must involve a final adverse determination.
- The health care coverage or plan 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, or the health carrier waived the exhaustion requirement.
Furthermore, if the request for external review involves issues of experimental or investigational service or treatment, DIFS has 5 business days to determine:
- 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 investigational, 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 PRIRA; and
- Whether the patient has submitted all required information to DIFS.
DIFS will notify you or your authorized representative in writing if the request for an external review is 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 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.
Independent Review Organization (IRO)
An IRO is an independent entity that has a contract with DIFS to conduct independent medical reviews under 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.
The IRO must consider the following in making a recommendation to DIFS:
- The covered person's pertinent medical records and attending health care professional's recommendation.
- Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, the covered person, the covered person's authorized representative, or the covered person's treating provider.
- The terms of coverage under the covered person's health plan with the health carrier.
- The most appropriate practice guidelines, which may include generally accepted practice guidelines, evidence-based practice guidelines, or any other practice guidelines developed by the federal government or national or professional medical societies, boards, and associations.
- Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review organization.
- Whether the requested health care service has been approved by the US Food and Drug Administration (FDA), if applicable; or
- 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).
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 the 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 they appeal 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, health, or ability to regain maximum function. 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.