As a result of the statutory mandate set forth in MCL 500.3157a, the Administrative Rules titled “Utilization Review” were created to provide procedures related to the insurer’s utilization review program and the provider appeal process.
Pursuant to Mich Admin Code, R 500.66, every automobile insurer providing Personal Injury Protection (PIP) insurance in Michigan is required to establish a certified utilization review program that complies with the utilization review administrative rules. The insurer’s utilization review program is required to review records and bills for treatment, training, products, services, and accommodations provided to auto accident victims and to make determinations regarding the appropriateness of provider treatment based on “medically accepted standards.”
If the insurer, under its utilization review program, issues a determination finding that a provider has overutilized or ordered inappropriate treatment, products, services, or accommodations, or that the cost of the treatment products, services, or accommodations was inappropriate, the provider may appeal the insurers determination to the Department of Insurance and Financial Services (DIFS).
Please see the DIFS Utilization Review - Frequently Asked Questions page for more information.
Insurers with a certified utilization review program must promptly update their contact information via the Auto Insurance Information Portal if there are any changes.
