(LANSING) - The Michigan Office of Financial and Insurance Services (OFIS) will begin the external review procedure for health insurance and health maintenance organization (HMO) complaints on October 1, 2000.

"The most important thing for you to know is if you have a complaint about a denial from your health insurance company call the Office of Financial and Insurance Services toll free at (877) 999-6442," said Commissioner Frank M. Fitzgerald. "Our staff will assist you with the external review process and make sure you are using the correct complaint process. Your health insurance company will also be providing information at the time of the denial."

Health insurance policies from health insurers, HMOs, Alternative Finance and Delivery Systems (AFDS) and Blue Cross/Blue Shield of Michigan (BCBSM) are eligible for the external review process. Medicare supplement, disability income, hospital indemnity, specified accident, credit, self funded plan health or long term care insurance policies do not qualify for the external review process. If you have a policy that does not qualify for external review, call OFIS toll free at (877) 999-6442 and staff will direct you to the process you need to use or forward you on to the correct agency. OFIS staff can also assist you in determining what kind of policy you have.

If you receive a denial and would like an external review, here are the steps to follow.

Step 1:
With any denial, your health insurance company will provide you with information on their internal grievance process. If you are denied a service that you think should be paid for, call the company that handles your health insurance and request an internal review.

Internal Review Process = The health insurance company will review the decision and get a final decision back to you within 45 days. The final decision is called a Final Adverse Determination. If the Final Adverse Determination still denies the medical service, you may request an External Review. Your health insurance company will send you information about the External Review with the Final Adverse Determination, including the OFIS Health Care Request for External Review form.

Step 2:
After the internal review process is complete, the External Review portion of this process is done by OFIS staff. Fill out and send in the external review form that your health insurance company sent with your Final Adverse Determination. You can also get copies of the form by calling OFIS toll free (877-999-6442) or visiting our Web site at www.cis.state.mi.us/ofis.

OFIS staff will review your request to make sure you are covered for the service. You will be notified within 5 days if your request has been sent on to an Independent Review Organization.

If you are covered, your request will be forwarded on to an Independent Review Organization. The Independent Review Organization reviews your medical information and the denial from your health insurance company. OFIS staff will review the Independent Review Organization recommendation and issue a final decision.

Your request will not be sent to an Independent Review Organization if OFIS staff has determined that the service you are requesting is not covered. If you are not covered, the external review is over and the denial stands.

Within 35 days of your request, OFIS staff will contact you with a final decision on the denial. If you are not satisfied with the external review decision, you can take the matter to court.

IN CASE OF AN EMERGENCY - If your doctor thinks that this denial jeopardizes your health in any way, this entire process can be completed within 72 hours. For more information, please see the Expedited External Review section of the Health Care Request for External Review form or call OFIS toll free at (877) 999-6442.

The external review process is part of recently enacted HMO reform legislation (Public Acts 187 & 249 - 252). The legislation also shortened grievance timelines, increased financial standards for HMOs, created an HMO consumer guide and addressed the payment of Medicaid claims. The HMO Consumer Guide will be available from OFIS in January 2001. The timely Medicaid claims process will address claims with a date of service on or after October 1, 2000. A claim is eligible for this process if it is unpaid after 45 days so OFIS will begin reviewing claims after November 15, 2000.