Health Care Provider

A “determination” defined under the Administrative Rules is a notice from an auto insurer to a health care provider that sets forth the auto insurer’s position that the health care provider overutilized or otherwise rendered or ordered inappropriate treatment, training, products, services, or accommodations, or that the cost of the treatment, etc., was inappropriate under Michigan law.

If the auto insurer’s determination includes a request for explanation under Mich Admin Code, R 500.63, follow the steps below:

• Request for Explanation
  An auto insurer may ask a health care provider to explain in writing the necessity or indication for an injured person’s treatment, training, products, services, or accommodations. This is called a “request for explanation” under the Administrative Rules. An auto insurer must submit this request to the health care provider within 30 days of the auto insurer’s receipt of the health care provider’s bill. See Mich Admin Code, R 500.63.
• Replying to a Request for Explanation
  Pursuant to Mich Admin Code, R 500.63(3), a health care provider must respond to the auto insurer’s written request for explanation within 30 days of the request. When responding, the health care provider should send the requested information directly to the auto insurer or claim representative for review. The health care provider’s written response may include reference to medical records, medical bills, or other information concerning the treatment, training, products, services, or accommodations provided to the injured person.
• Reimbursement for Explanation Requests
  If the auto insurer’s request requires the health care provider to send medical records, bills, or other documentation in excess of that which customarily accompanies a bill submitted to the auto insurer, the auto insurer must reimburse the health care provider at a reasonable and customary fee, plus the actual costs of copying and mailing, within 30 days of the auto insurer’s request. See Mich Admin Code, R 500.63(4).
• Determination following Explanation Requests
  After receiving the health care provider’s written explanation, the auto insurer must either pay the bill or deny payment, either in part or in full. When denying payment, the auto insurer must issue a written notice of determination to the health care provider within 30 days of the auto insurer’s receipt of the health care provider’s explanation.
• Expiration of Explanation Requests
  A health care provider may file an appeal request to DIFS after the 30-day period to respond to the auto insurer has lapsed.

To request an auto insurance utilization review provider appeal, the health care provider must email a completed Auto Insurance Utilization Review Provider Appeal Request (FIS 2356) form and all required supporting documentation to DIFS-URAppeals@michigan.gov. To be considered timely, a utilization review appeal to DIFS must be filed within 90 days of the date of the auto insurer’s disputed determination or bill denial.

An appeal received after 90 days of the date of the determination cannot be reviewed by DIFS but may still be resolved directly with the auto insurer.

DIFS' decisions are based on documentation provided by both parties. It is the health care provider’s responsibility to ensure all necessary and relevant documentation is provided with the Auto Insurance Utilization Review Provider Appeal Request (FIS 2356) form at the time the appeal is filed. DIFS will not accept additional supporting documentation after an appeal request has been filed.

Required Documentation

• Medical Necessity Dispute
  In addition to the completed FIS 2356 form, the health care provider is required to provide:
• A detailed narrative explaining the reason for the appeal request, the desired outcome, and—as applicable—the health care provider’s basis for its position that the treatment, etc., was appropriate under Michigan law and/or the amount the health care provider believes they are owed for the treatment, etc., in dispute.
• All pages of each determination/denial in dispute (e.g., Explanation of Benefits, Explanation of Review, Reconsiderations, etc.).
• The billing claim form for the service(s) at issue.
• All supporting documentation and medical records related to the appeal request.

• Cost Dispute
• Accidents Prior to June 11, 2019
  In addition to the completed FIS 2356 form, the health care provider is required to provide:
• A detailed narrative explaining the reason for the appeal request, the desired outcome, and—as applicable—the health care provider’s basis for its position that the treatment, etc., was appropriate under Michigan law and/or the amount the health care provider believes they are owed for the treatment, etc., in dispute.
• All pages of each determination/denial in dispute (e.g., Explanation of Benefits, Explanation of Review, Reconsiderations, etc.).
• The billing claim form for the service(s) at issue.
• Accidents on or after June 11, 2019
  In addition to the completed FIS 2356 form, the health care provider is required to provide:
• A detailed narrative explaining the reason for the appeal request, the desired outcome, and—as applicable—the health care provider’s basis for its position that the treatment, etc., was appropriate under Michigan law and/or the amount the health care provider believes they are owed for the treatment, etc., in dispute.
• All pages of each determination/denial in dispute (e.g., Explanation of Benefits, Explanation of Review, Reconsiderations, etc.).
• The billing claim form for the service(s) at issue.
• A copy of the health care provider’s charge description master (CDM) in effect on January 1, 2019, or, if the health care provider does not have a charge description master, the average amount charged for the service on January 1, 2019. If the treatment, product, service, or accommodation was not being offered on January 1, 2019, or, if the health care provider’s business was not established on January 1, 2019, please indicate this on the detailed narrative which explains the reason for the appeal request.
• The Auto Insurance Utilization Review Provider Attestation (FIS 2376) form.

Tips for successful appeal request submissions

• Completing the FIS 2356 form
  • If the health care provider does not have a National Provider Identifier (NPI), please write N/A in this field on the FIS 2356 form.
  • An auto insurer’s date of determination (DOD) is often called the “Approved Date,” “Post Date,” “Document Date,” “Reviewed,” “Check Date,” or will otherwise be located in the upper right-hand corner or the middle of the bottom of the document.
  • When listing the dates of service at issue, date ranges are not acceptable unless services were rendered on each date included in the range.
  • Please list the procedure codes at issue and not the diagnoses codes.
• Sending appeal requests to DIFS
  • Faxed appeal requests are no longer accepted.
  • A health care provider may submit the appeal request and supporting documentation in more than one email if needed. If more than one email is required to submit the appeal request, all associated emails must be labeled as 1 of 2, 2 of 2, etc., as applicable.
  • DIFS does not accept documentation sent through OneDrive, Google Docs, or via unsecured file-sharing platforms. DIFS also does not accept documentation sent in a JPEG/JPG format. All documentation must be attached directly to the email in either PDF, Excel, or Word format.
  • While submission through email is preferred, appeal requests may be submitted through U.S. postal mail; however, the health care provider is responsible for accounting for longer processing times for the appeal to reach DIFS. Mailed requests can be sent to: DIFS, PO Box 30220, Lansing, MI 48909-7720. If a health care provider elects to send an appeal to DIFS via USPS Overnight services, it should be addressed to: DIFS, 530 W. Allegan Street, 7th Floor, Lansing, MI 48933.
• When to follow up?
  Once an auto insurance utilization review provider appeal request is sent to DIFS, the email address listed under the Provider Information section of the FIS 2356 form should receive additional information within 21 days. If more than 21 days have passed since submission of the appeal request, and the health care provider has not received any communications from DIFS, please email DIFS-URAppeals@michigan.gov.

DIFS will send a copy of the Notice of Appeal via email to the involved parties within 14 days of accepting a provider appeal request. The Notice of Appeal is sent to the health care provider and injured person for notification purposes only and no additional action is required from the health care provider at this stage. If action is needed, DIFS staff will contact the health care provider’s point of contact via email outlining what is needed and a deadline for reply.

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 health care provider is encouraged to maintain this information, as this is the only document that will be sent which includes the injured person’s full name.

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. While the parties are encouraged to engage in informal communications, the auto insurer is given a DIFS email address where they can submit a completed Insurer Reply to Provider Appeal (FIS 2361) form.

If the health care provider receives questions from the injured person about the appeal, the health care provider should inform the injured person that the injured person has no active role in the process.

Once the Final Order has been issued, DIFS will email a copy of the order to the health care provider and auto insurer.

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.