Depart of Licensing and Regulatory Affairs - Utilization Review - Administrative Code R 500.61 - R 500.69
(By authority conferred on the director of insurance and financial services by section 3157a of the insurance code of 1956, 1956 PA 218, 500.3157a, and Executive Reorganization Order No. 2013-1, MCL 550.991)
If a provider’s treatment for an injured person appears excessive, an insurer may request a written explanation from the provider within 30 days of receipt of the bill. The provider must respond within 30 days of receipt of the request for explanation. The insurer must reimburse the provider for the cost of copying and mailing medical records, bills, or other information if necessary.
If an insurer finds that the provider rendered or ordered inappropriate or excessive treatment, the insurer must issue a written notice of the determination, including specified information, to the provider within 30 days of receipt of the provider’s written explanation. The notice must include the criteria or standards used by the insurer with specific reference to the insurer’s utilization review program.
A provider may appeal the determination within 90 days. The insurer may file a reply to the provider’s appeal within 21 days of notification of the appeal by DIFS. DIFS must issue a decision within 28 days.
Utilization Review Program
By February 16, 2021, insurers must have in place and submit to DIFS for review and certification a utilization review program to review records, bills, and other information. The program must set forth standards for making a determination as to whether the treatment was excessive. DIFS must issue a certification no later than 90 days after it is submitted, although the director may request an additional 30 days.
The certification may be either conditional or unconditional, with the unconditional being issued for a period of three years. A conditional certification is issued if DIFS determines that the insurer does not meet the required criteria. If the insurer agrees to undertake corrective action, then conditional certification may be granted by the department for a maximum period of 1 year.
Insurers must apply for renewal no less than 90 days prior to the expiration of the insurer’s current certification. Additional information, including necessary forms, can be accessed on the DIFS Website. Beginning in 2022, insurers must submit a Utilization Review Annual Report by March 31.
Insurers and providers must retain copies of all requests, explanations, and determinations issued under these rules for at least two years after the date of the request, explanation, or written notice, and must submit them to DIFS upon request.