MICHIGAN

If your insurer denies your claim, you have the right to submit an internal grievance.^[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file a grievance, you should do the following:

• Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
• Collect information. In addition to the determination letter, collect the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
• Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing a grievance, call your insurer and request these documents.
• Call your health care provider’s office. Contact your health care provider’s office to ask for help with the grievance process. Someone in his or her office might help you fill out the forms to request a grievance and draft a strong grievance letter.
• Submit the grievance request. You or someone in your health care provider’s office should submit the grievance forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
• Request an expedited internal grievance, if applicable. You can also submit an expedited internal grievance in writing to your health insurer. To qualify for an expedited internal grievance, your health care provider must certify to your insurer, over the phone or in writing, that the time frame for resolving a standard internal grievance would seriously jeopardize your life, health, or ability to regain function.^[2]
• Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the grievance, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

The internal grievance process should take a maximum of 30 calendar days plus an additional ten business days if your insurer has not received requested information from a health care provider or health care facility.^[3] The expedited grievance process should take no longer than 72 hours after the insurer receives your expedited grievance request.^[4]

You are entitled by law to request an external review from an independent third party, which means your insurer no longer has the final say over whether to approve a treatment or pay a claim. Under Michigan law, you are entitled to an external review if:

• Your insurer denies, reduces, or terminates your coverage; and
• You have completed the internal grievance process or your insurer does not provide you with a decision within the allotted time.^[5]

You may also request an expedited external review if your medical situation is urgent and waiting 35 days would jeopardize your life or ability to function. You may request an expedited external review while you request an expedited internal grievance.^[6]

You should submit your request for external review to the Michigan Department of Insurance and Financial Services (“Department”) within 60 days from the date that your insurer sent you the final decision. If you are requesting an expedited external review, you must submit your request within ten days of receipt of the most recent decision letter.^[7]

Information. You can find a copy of the external review request form here. Your request should include the following information:

• The name, address, telephone number, and relationship to patient of the person filing the request;
• The patient’s name;
• The name of the insured person;
• The name of your health insurer;
• The policy number, group number, and claim number, if applicable;
• Dates service was received or requested;
• The name of the physician and medical facility involved;
• A description of the problem involved.^[8]

Supporting document. You should also include the following supporting documents with your request:

• A copy of the final adverse determination letter;
• Copies of bills, explanations of benefits, and medical records related to the request;
• Copies of correspondence between you and the health insurer;
• Statements from doctors; and
• Any research material that supports your position.^[9]

Where to submit for a standard external review. You can submit the request and supporting documents by fax to (517) 284-8838, by email to DIFS-HealthAppeal@michigan.gov, or by mail to:^[10]

DIFS-Office of General Counsel-Appeals Section
P.O. Box 30220
Lansing, MI 48909-7720

Where to submit for an expedited external review. If you are requesting an expedited external review, you should submit your request and supporting documents by courier or delivery to the following address:

DIFS-Office of General Counsel-Appeals Section
530 W. Allegan Street, 7^th Floor
Lansing, MI 48933^[11]

If you have any questions, you can call the Department at (877) 999-6442.

If your case involves a decision regarding provisions of your insurance contract or policy, the review will be conducted by the Director of the Department. If your case involves a question of medical necessity, it will be referred to an independent review organization for review.^[12]

• Issue with your policy. If your case involves a decision regarding part of your insurance contract or policy, the Department has 14 calendar days to give you a decision.
• Question of medical necessity. If the medical necessity of your treatment is at issue, the Department has 21 days to provide you with a decision.^[13]
• Expedited external review. If you requested an expedited external review, the Department has 72 hours to provide you with a decision.^[14]

If you are a Michigan resident and your insurer still denies your coverage after the external review process, you can file a complaint with the Department.

Complaint information. Your complaint should include the following information:

• The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
• The name of the insured individual, if different than the Complainant;
• The date of the healthcare service;
• The name of insurance company and name of agent or agency, if applicable;
• The policy number, group contract number, and name of group/employer, if applicable;
• The reason for the complaint;
• The details of the complaint; and
• What you consider to be a fair resolution.

Supporting documents. You should also submit the following supporting documents with your complaint:

• A copy of your insurance card;
• Copies of coverage denials or adverse benefit determinations from your insurer;
• Copies of any determinations made by internal and external reviewers;
• Any materials submitted with prior grievances and complaints;
• Supporting documentation from your doctor;
• A copy of your insurance policy; and
• All responses from your insurer.^[15]

How to submit. You can submit the complaint online here, faxed to (517) 284-8837, emailed to difs-hicap@michigan.gov, or mailed to the following address:^[16]

DIFS – Office of Consumer Services
P.O. Box 30220
Lansing, MI 48909-7720

Once the Department receives your complaint, it will forward a copy to your health insurer and ask for a response. For policies issued before July 1, 2016, the insurer has 35 days to respond to the complaint. For policies issued after July 1, 2016, the insurer has 60 days to respond to the complaint. The Department will complete an investigation and provide you with a decision.^[17] The Department may force the insurer to comply with the policy, issue a citation, or fine the insurer if it finds the insurer has violated a state law or regulation.

You can contact the Michigan Department of Insurance and Financial Services at (877) 999-6442. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.