Health Coverage Grievances and Appeals
INTERNAL GRIEVANCE PROCESS:
Under Michigan laws, each health carrier must establish an internal formal grievance process. This process provides the member or their authorized representative an avenue to seek resolution when there has been an adverse determination. An adverse determination is an admission, availability of care, continued stay, or other health care service that has been reviewed and has been denied, reduced, or terminated. Failure to respond in a timely manner to a request for a determination constitutes an adverse determination. The health carrier is required to make sure all steps in the internal grievance process are completed within 35 calendar days after the written request has been submitted. This does not include the time the patient takes to decide to go from one step in the process to the next step in the process. The health carrier can request an additional 10 business days to obtain necessary medical information. However, this additional time can only be granted if the person who filed the grievance agrees to such a delay.
BEGINNING THE INTERNAL GRIEVANCE PROCESS:
The first step in the internal grievance process is to provide your health carrier with a written grievance, which consists of your written statements regarding the facts of the issue and your position. Your health carrier is required to provide you with the address to submit the written grievance and any special forms, as well as information on how to begin the internal grievance process. After you submit the written grievance to your health carrier, your health carrier is required to notify you of its determination in writing and to advise you of your right to the next step(s) in the grievance process if you disagree with the determination and your rights to an external review.
FURTHER STEPS IN THE INTERNAL GRIEVANCE PROCESS:
The next step in the internal grievance process may give the patient the right to appear before the board of directors or designated committee or the right to a managerial-level conference to complete the grievance (this will depend on the number of steps in the internal grievance process-but this step must be offered). After this step, the health carrier is required to notify the patient of its determination in writing and to advise the patient of the external review process and the right to an external review with the Department of Insurance and Financial Services (DIFS) under the Patient's Right to Independent Review Act; or, other external review processes that may be available to the patient.
PATIENT'S RIGHT TO INDEPENDENT REVIEW ACT (PRIRA):
The Patient's Right to Independent Review Act (PRIRA) is a Michigan law that provides patients with appeal rights due to adverse decisions made by health carriers regarding a denial, reduction, or termination of health care services. The PRIRA external review process applies after the patient has exhausted the health carrier's internal grievance process. The PRIRA external review process does not apply to a medical provider's complaint concerning claims payment, handling, or reimbursement for health care services. You are only eligible for the external review process if you have completed the internal grievance process of your health carrier, or if they fail to complete the internal process (35 to 45 days).
REQUIRED INFORMATION FOR PRIRA EXTERNAL REVIEW:
To request an external review under the PRIRA, the patient or their authorized representative must complete the Health Care Request for External Review Form. The request should also include a copy of the final adverse determination from the health carrier along with information and documentation to support the patient's position. The request must be submitted within 60 days of the patient's receipt of the health carrier's final adverse determination.
APPOINTMENT OF AUTHORIZED REPRESENTATIVE:
Michigan law provides that the patient may authorize in writing any person such as a doctor, attorney, parent or spouse to represent them in the internal grievance process and/or the PRIRA external review process. In the PRIRA external review process, this person is called an authorized representative and can be a person authorized by law to represent the patient. The Health Care Request for External Review Form provides space to authorize a representative who will act on behalf of the patient with respect to a request for external review and will be DIFS's sole contact in the PRIRA external review process.
ATTORNEYS IN PRIRA EXTERNAL REVIEW PROCESS:
Patients and their authorized representative are not required to have an attorney represent them through the PRIRA external review process.
PRELIMINIARY REVIEW OF REQEUST FOR PRIRA EXTERNAL REVIEW:
DIFS has 5 business days to conduct a preliminary review to determine if the patient is eligible for the PRIRA external review process. DIFS notifies the health carrier of the request and obtains pertinent information to help decide if the patient and health care service is eligible for a PRIRA external review. DIFS makes sure the request meets the following requirements:
The issue must involve an adverse determination
The coverage involved must be subject to the Patient's Right to Independent Review Act
The patient must have been a covered person at the time the health care service was provided or requested
The health care service in question must reasonably appear to be a covered service under the contract or policy
The covered person must have exhausted the internal grievance process of the health carrier
DIFS will notify the patient or their authorized representative in writing if the request is accepted or not accepted for external review under the PRIRA. Occasionally requests are determined to be incomplete in which case we advise the person of the information needed to make the request complete. If the request is not accepted, DIFS will explain the reason why the request does not qualify for an external review under the PRIRA.
If the request is accepted and involves only contractual provisions of the contract or policy, the review is conducted by the Director of DIFS. If your request is accepted and involves issues of medical necessity or clinical review criteria, it is referred to an independent review organization (IRO).
INDEPENDENT REVIEW ORGANIZATION (IRO):
An IRO is an independent entity that has a contract with DIFS to conduct independent medical reviews under the PRIRA. The contracted individuals reviewing the issues have medical expertise in the health care service at issue in the review.
INVESTIGATION AND OBTAINING THE PATIENT'S MEDICAL RECORDS:
DIFS staff will not investigate, contact medical sources or seek out information to support the patient's position. It is the patient's responsibility to provide the pertinent documents such as bills, explanations of benefits, medical records, correspondence, statements from doctors and research material to support their own position. If the issue in the review is referred to an IRO, the health carrier is required to provide the IRO with the medical records and other documents it used in making its determination. The IRO will use this information as part of its research into the issue.
If the PRIRA external review is conducted by the Director and does not require review by an IRO, the law requires that the Director issue a decision within 14 calendar days after the request is accepted for review. If the review requires referral to an IRO, the IRO is required to provide DIFS with its recommendation within 14 calendar days after it is assigned the review. The law requires that the Director issue a decision within 7 business days after it receives the recommendation of the IRO.
RIGHT TO APPEAL DIRECTOR'S DECISION:
If the patient, authorized representative, or the health carrier disagrees with the Director's decision, either party has the right to appeal to circuit court in the county where the covered person resides or in Ingham County within 60 days from the date of the decision. If the decision overturns the health carrier's determination and the health carrier appeals to circuit court, DIFS will not represent the patient in circuit court.
PRIRA EXPEDITED EXTERNAL REVIEW:
A PRIRA expedited external review is a faster review process available when an adverse determination involves a medical condition for which the timeframe for completion of the PRIRA external review would seriously jeopardize the life or health of the patient or would jeopardize the patient's ability to regain maximum function. A PRIRA expedited external review is completed within 72 hours after your request (which DIFS prefers in writing) has been accepted for expedited external review.
To qualify for a PRIRA expedited external review, the patient must have a physician verify, orally or in writing, that the time frame for a non-expedited PRIRA external review would seriously jeopardize the life or health of the covered person. A PRIRA expedited external review is only granted when the issue involves health care services that have not already been provided to the patient and the issue involves medical necessity of a serious medical condition.
The same form is used to request an expedited external and non-expedited review under the Patient's Right to Independent Review Act: Health Care Request for External Review Form