04/30/2021

Michigan Department of Insurance and Financial Services Advises Consumers of Free Process to Appeal Health Insurer Denials

(LANSING, MICH) The Michigan Department of Insurance and Financial Services (DIFS) is reminding consumers of an important free tool for consumers to appeal an insurer’s denial of a health insurance coverage decision or claim.

“Consumers may feel frustrated when their health insurance company denies coverage for a medical treatment or service, and they may not know that they have another opportunity to be heard if they are not satisfied with the results of the insurer’s internal appeal process,” said DIFS Director Anita Fox. “Michigan’s Patient’s Right to Independent Review Act (PRIRA) gives consumers the opportunity to have an external review of health insurance decisions to obtain the health care services to which they are entitled.”

When a health insurer decides that a health care service will not be covered, it will issue an official notification called an “adverse determination.” If a consumer disagrees with that decision, the consumer has the right to file an appeal. There are two levels of appeal:

• an internal grievance, initiated by the consumer with their health insurance company and;
• an external review with DIFS, which may be initiated after the consumer has gone through the health insurer’s internal grievance process or if the insurer fails to provide a decision within the timeframe required by law, which is 30 calendar days for a pre-service denial or 60 days for a post-service denial.

Since 2019, DIFS has issued nearly 1,000 PRIRA orders to health insurance companies. For more information related to filing a request for an external review, contact DIFS 8 a.m. to 5 p.m. Monday through Friday at 877-999-6442 or visit the DIFS PRIRA website. Consumers have 127 days after they receive the health insurer’s final denial to file a request for external review with DIFS.

Consumers may request an expedited external review in situations where the normal PRIRA review timeframe could seriously jeopardize their life, health, or ability to regain maximum function. Expedited reviews require that the treating physician verify the necessity of expediting the external review and are conducted within 72 hours. The normal PRIRA process many take a significant period of time to be resolved.

“It is important that Michiganders know about PRIRA so that they can take advantage of this key consumer protection,” said Fox. “DIFS is first and foremost a consumer protection agency and we are always here to help answer questions or concerns that consumers might have related to their insurance or financial services.”

DIFS can help consumers with health insurance questions and complaints and can provide information about the current Health Insurance Marketplace Special Enrollment Period that will be open through August 15. Contact DIFS Monday through Friday from 8 a.m. to 5 p.m. at 877-999-6442 or Michigan.gov/HealthInsurance.

The mission of the Michigan Department of Insurance and Financial Services is to ensure access to safe and secure insurance and financial services fundamental for the opportunity, security, and success of Michigan residents, while fostering economic growth and sustainability in both industries. In addition, the Department provides consumer protection, outreach, and financial literacy and education services to Michigan residents. For more information, visit Michigan.gov/DIFS or follow the Department on Facebook, Twitter, or LinkedIn.