Insurance

Supplemental IPPS Calculation Form

Domestic Insurer Exemption Certification

UPDATED 1/5/2024 - Use this link for complete form and instruction packets.

(This template is no longer used. Use FIS 2385 Michigan Network Adequacy Template)

Checklist for Individual and Small Group MEDICAL Plans - FORMS

Checklist for Individual and Small Group MEDICAL Plans - RATES

Checklist for Individual and Small Group STAND-ALONE DENTAL Plans - FORMS

Checklist for Individual and Small Group STAND-ALONE DENTAL Plans - RATES

MI Uniform Modification Justification Documentation form

Checklist for Individual and Small Group MEDICAL Plans - NETWORK ADEQUACY

Checklist for Individual and Small Group STAND-ALONE DENTAL Plans - NETWORK ADEQUACY

Stand-Alone Dental Plan Actuarial Value Supporting Documentation and Justification

Pursuant to 18 USC Section 1033 and 1034

Pharmacy Benefit Manager (PBM) Network Adequacy Request for Waiver

Financial Statements for Pharmacy Benefit Managers (PBMs)

Pharmacy Benefit Manager - Consent to Service

PBM Network Adequacy Template

Pharmacy Benefit Manager (PBM) Application

Pharmacy Benefit Manager (PBM) Modification of Information

Pharmacy Benefit Manager (PBM) Affiliation Statement

Pharmacy Benefit Manager (PBM) Complaint Form

Pharmacy Benefit Manager – Certificate of Compliance

Pharmacy Benefit Manager (PBM) Transparency Report

Fee Processing Card for Pharmacy Benefit Manager

Prior Authorization Practices and Experience Checklist

Application for Self-Insurance Certificate

On January 1, 2013, the Department of Insurance and Financial Services (DIFS) assumed responsibility for the licensing and administration of the motor vehicle self-insurance program in accordance with Public Act No. 204 of 2012.

Surprise Medical Billing Arbitrator Form

Request for Binding Arbitration Form

Request for Review of Calculation of Charges Form

Response to Calculation Review Request Form