Under Michigan's auto insurance law, medical care provided to a person injured in an auto accident must meet certain requirements for medical appropriateness. Auto insurers must establish utilization review programs to make these determinations, which can be appealed by health care providers to the Michigan Department of Insurance and Financial Services (DIFS) Utilization Review (UR) section.
Below is a list of all Utilization Review forms and their purpose.
- Application for Unconditional Certification of Auto Insurance Utilization Review Program(FIS 2362)
The Application for Unconditional Certification of Auto Insurance Utilization Review Program (FIS 2362) is utilized by insurers providing personal protection insurance under Chapter 31 of the Insurance Code, MCL 500.3101 to 500.3179, and rules promulgated thereunder, to request initial, renewal, or reimstatement, of its unconditional certification of their auto insurance utilization review program.
- Auto Insurance Utilization Review Provider Appeal Request (FIS 2356)
The Auto Insurance Utilization Review Provider Appeal Request (FIS 2356) is utilized when a health care provider disagrees with a utilization review determination related to the utilization or cost of an injured person’s treatment, training, products, services, or accommodations made by an auto insurer or the Michigan Catastrophic Claims Association (MCCA). To request an auto insurance utilization review provider appeal, the heatlh care provider must submit the completed FIS 2356 form and all required supporting documentation to DIFS for review.
- Auto Insurance Utilization Review Insurer Reply to Provider Appeal (FIS 2361)
The Auto Insurance Utilization Review Insurer Reply to Provider Appeal (FIS 2361) is utilized by the auto insurer to file a reply to DIFS after receipt of a Notice of Appeal and supporting documentation. Submitting the FIS 2361 form allows the auto insurer the ability to explain the basis for its utilization review determination and provide any documentation that supports their position.
- Auto Insurance Utilization Review Insurer Annual Report (FIS 2358)
On an annual basis, auto insurers must submit an Auto Insurance Utilization Review Insurer Annual Report (FIS 2358) to DIFS no later than March 31 of each year. The FIS 2358 form is used to provide DIFS with information regarding any material changes to the auto insurer's utilization review (UR) program and the preceding year's UR activities.
- Auto Insurance Utilization Review Provider Attestation (FIS 2376)
The Auto Insurance Utilization Review Provider Attestation (FIS 2376) form is utilized by health care providers who appeal a determination to DIFS, to attest that the information provided on its charge description master in effect on January 1, 2019, or average amount charged for a service on January 1, 2019, is accurate.
- Application for Designation as Freestanding Rehabilitation Facility (FIS 2364)
The Application for Designation as Freestanding Rehabilitation Facility (FIS 2364) is utilzed by freestanding rehabilitation facilities meeting the qualifications under MCL 500.3157(4)(b), to apply for enhanced reimbursement under Section 3157(3) of the Code, MCL 500.3157(3).
