Utilization Review Process

Editorial Board member, Katie Tucker, explains Michigan’s new Utilization Review.

The Utilization Review Process

Part I:  Record Acquisition and Requests for Explanation

The first stage of the utilization review process involves record acquisition.  Specifically, it involves insurers submitting requests for additional information and documentation and providers responding to those requests.

Under Rule 63(1) of the new UR Rules, within 30 days of receipt of a provider’s bill, an insurer or the MCCA may request that a provider explain the need or indication for treatment in writing if the treatment falls into any of the following 4 categories:

• It is not usually associated with the treatment that is “usually required”;
• It is longer in duration than the treatment that is “usually required”;
• It is more frequent that the treatment that is “usually required”; or
• It extends over a greater number of days than treatment that is “usually required”

Under Rule 63(2), an insurer or the MCCA may request that the provider include any of the following in its written explanation:

• Medical records;
• Bills; or
• Other information concerning the treatment

Under Rule 63(3), within 30 days of receipt of an insurer’s request, a provider must supply a response.

In addition, under Rule 63(4), within 30 days, the insurer must reimburse the provider for its “reasonable and customary fee” and the “actual costs of copying and mailing” incurred by the provider in responding to the insurer’s request.

A chart summarizing these timelines is available here.

Part II:  Initial Determinations by Insurer or the MCCA

The second stage of the utilization review process involves determinations by an insurer or the MCCA.  Specifically, it involves initial determinations as to the appropriateness of treatment provided and the cost of that treatment.

Under Rule 64(1) of the UR Rules, after reviewing a provider’s written explanation, an insurer or the MCCA may determine that:

• A “provider overutilized or otherwise rendered or ordered inappropriate treatment, training, products, services, or accommodations”; and/or
• The “cost of the treatment, training, products, services or accommodations was inappropriate . . .”

The insurer or the MCCA must notify the provider of this determination by issuing a written notice within 30 days of receipt of the provider’s written explanation.  Under Rule 64(1), the written notice must include all of the following:

• “The criteria or standards on which the insurer relied . . . with specific reference to [its] utilization review program . . .”
• “The amount of payment to the provider . . . including explanation of difference between that amount and amount billed . . .”
• “If applicable, a description of any additional records the provider must submit . . . in order for the insurer to reconsider . . .”
• “A copy of the [appeal form] referenced in [Rule 65].”
• “The date of the determination.”

Part III:  Provider Appeals to DIFS

The third stage of the utilization review process involves provider appeals of insurers’ determinations.  Specifically, if a provider disagrees with the initial determination of an insurer or the MCCA as to the appropriateness of the treatment the provider has rendered or the cost of that treatment, the provider may appeal that determination to DIFS.

Provider’s Appeal Request

Under Rule 65(1), a provider’s appeal to DIFS must be filed within 90 days of the date of the determination by the insurer or the MCCA.   Further, the appeal must be filed on the form prescribed by DIFS, entitled “No-Fault Utilization Review Provider Appeal Request,” a copy of which can be accessed here.  The appeal request form requires a provider to supply information regarding the following:

• Provider and Claim Information;
• Contact Information for the Insurer/Association and Injured Person; and
• Information on Appeal Issues

In addition to this information, a provider must also include the following documents:

• A detailed statement of the reason(s) for the request for review; and
• A copy of the insurer or the MCCA’s notice of determination, pursuant to Rule 64(1), and/or a denial of the provider’s bill, pursuant to Rule 64(3).

As part of its appeal request, a provider may also include any of the following documents:

• All documents related to requests for explanation exchanged between provider and insurer prior to this appeal request, pursuant to Rule 63;
• Pertinent clinical information; and/or
• Other supporting documents

A copy of the completed appeal request form and any attachments should be transmitted to DIFS by e-mail to DIFSURAppeals@michigan.gov and/or by fax to (517) 763-0305.

DIFS’ Notification

Under Rule 65(2), within 14 days of submission of a provider’s appeal request, DIFS shall notify the insurer or the MCCA and the injured person of the provider’s appeal.  In addition, within that same period, DIFS must “request any additional information necessary to review the appeal.”

Reply by Insurer or the MCCA

Under Rule 65(3), within 21 days of the date of DIFS’ notice, an insurer or the MCCA may file a reply to the provider’s appeal.

DIFS’ Determination

Under Rule 65(5), within 28 days after an insurer or the MCCA files its reply (or the time for doing so expires), DIFS’ Director shall issue a decision on the provider’s appeal.  However, if additional time is needed, the DIFS Director “may take an additional 28 days to issue a decision” upon written notice to the insurer or the MCCA and the provider.

The decision by the DIFS Director shall be based solely on the written materials submitted by the parties.  There is no hearing or opportunity to present oral argument or testimony before the DIFS Director issues a decision.

Judicial Review

Under Rule 65(7), the DIFS Director’s decision is subject to “judicial review” as provided in §244(1) of Michigan’s Insurance Code.  That statutory section provides that “[a] person aggrieved by a final order, decision, finding, ruling, opinion, rule, action, or inaction provided for under this act may seek judicial review in the manner provided for in chapter 6 of the administrative procedures act of 1969, 1969 PA 306, MCL 24.301 to 24.306.” MCL 500.244.

If you have any utilization review-related questions for the ANFL Editorial Board, please submit them to autonofaultlaw@sinasdramis.com.