The Department of Insurance and Financial Services (DIFS) will email a copy of the Notice of Appeal to the parties within 14 days of accepting a provider appeal request. The Notice of Appeal will outline the injured person’s name, the Utilization Review (UR) case number assigned to the appeal, and the date(s) of service and procedure code(s) being reviewed in that case.
The Notice of Appeal allows the auto insurer or Michigan Catastrophic Claims Association (MCCA) the ability to file a written reply to DIFS which outlines their position regarding the health care provider’s appeal and the determination in dispute.
The auto insurer or MCCA must submit a reply to DIFS using the Auto Insurance Utilization Review Insurer Reply to Provider Appeal (FIS 2361) form and must be received no later than 21 days after the date on the Notice of Appeal. The form and any supporting documentation must be emailed to DIFS at DIFS-URAppeals@michigan.gov.
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 Insurer Reply to Provider Appeal (FIS 2361) form.
DIFS will issue an order resolving the appeal to both the health care provider and the auto insurer or the MCCA. If DIFS requires additional time to complete the decision, a written notification of extension will be emailed to the health care provider and the insurer or the MCCA.
A person aggrieved by the order may seek judicial review by contacting the County Circuit Court in the county in which they do business. Once filed with the County Circuit Court, a copy of the petition for judicial review should be sent to the Department of Insurance and Financial Services, Office of Appeals and Market Regulation, Post Office Box 30220, Lansing, MI, 48909-7720.
To view official Utilization Review orders issued by DIFS please visit Utilization Review Orders.
If an auto insurer’s or MCCA’s determination is reversed in the DIFS order, the auto insurer or MCCA shall, within 21 days of the date stated in the Certificate of Service for the order, submit proof that it has complied with this order.
Proof of compliance must be submitted to DIFS-URAppeals@michigan.gov and must include the case number, a brief explanation of how the submission satisfies the order, and any supporting documents (e.g., EOB, payment proof, or explanatory letter if no payment is due).
Pursuant to Mich Admin Code, R 500.65(6), interest is due on any overdue payments as set forth in Section 3142 of the Code, MCL 500.3142.
