Appealing a Decision Made by Your Health Insurer
If you disagree with a decision your health insurer made regarding your health care claim, you have the right to appeal the decision. There are two levels of appeal – an internal appeal with your health insurer and an external review with the Department of Insurance and Financial Services (DIFS).
An external review process should only be initiated if:
The covered person has exhausted the health carrier’s internal grievance process.
The health carrier fails to provide a determination within the timeframe dictated by law.
What You Should Know
- Internal Appeal Process
Michigan law provides you the right to file an internal appeal if you disagree with your health insurer’s claim determination, also known as an adverse determination.
An adverse determination means that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been denied, reduced, or terminated. Failure to respond in a timely manner to a request for a claim determination is also an adverse determination.
When you receive an adverse determination notice, you must notify your health insurer in writing that you want to appeal their decision.
The adverse determination notice will provide the timeframe in which you are required to submit your written appeal. Once you file an appeal, the health insurer is required to complete the internal grievance process within:
- 30 calendar days for a pre-service denial.
- 60 calendar days for a post-service denial.
- External Review Process
If you do not agree with the health insurer’s final adverse determination, you have 127 days to file an external review under the Patient’s Right to Independent Review Act (PRIRA).
To request an external review, you or your authorized representative must complete the Health Care Appeals-Request for External Review form. In addition to the form, the external review request should include a copy of the final adverse determination from your health insurer, the reason(s) why you are appealing the decision, and any documentation to support your position.
If the external review concerns a denial based on an experimental and/or investigational service, your treating provider must complete the Treating Provider Certification for Experimental/Investigational Denials form and submit it with your request.
For additional information related to DIFS’ external review process contact DIFS at 877-999-6442. Upon receipt, DIFS will examine your external review request to determine if it meets the requirements under PRIRA.
If your request is accepted and involves a contractual dispute, the external review is conducted by DIFS. If your request is accepted and involves issues of medical necessity or clinical review, it is referred for review to an independent review organization. In both instances, the Director of DIFS will issue an order with the decision of the review.
- 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 Appeals-Request for External Review form provides space to authorize a representative, who will be DIFS' sole contact in the PRIRA external review process.
- Expedited External Review
You have the right to request an expedited external review in situations where the normal PRIRA review timeframe would seriously jeopardize your life, health, or ability to regain maximum function. An expedited external review is conducted within 72 hours and requires your treating physician to verify, orally or in writing, the necessity of an expedited review. You are not eligible for an expedited external review if it concerns a health care service that has already been received.
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