Whom to contact:

Michigan Office of Financial and Insurance Services (OFIS)

Who can appeal:

You or your authorized representative

What you can appeal:

The availability, delivery, or quality of health care services, including a complaint regarding an adverse determination, benefits or claims payment, handling or reimbursement for health care services, as well as issues concerning the contract between you and your health plan.

When you can appeal:

After denial for coverage has been appealed through the health plan’s internal process, you must file not later than 60 days from receipt of a notice of final adverse determination.

What to send:

• Completed OFIS Health Care Request for External Review form
• Copy of the written final adverse determination from your health plan
• Any additional supporting information.

What you must pay:

No charge

What will happen:

• OFIS reviews your request and checks that the denied service is covered.
• If the grievance involves non-medical issues, it will be reviewed by the Commissioner of OFIS.
• If the grievance involves medical issues, the request is assigned to an Independent Review Organization (IRO).
• The Independent Review Organization reviews medical information and the denial and makes a recommendation within 14 calendar days.
• OFIS reviews the recommendation of the Independent Review Organization.

When you will get a decision:

The review process takes approximately 26 days to complete:

• OFIS will review your request within 5 business days.
• The IRO has 14 calendar days to evaluate your case and make a recommendation.
• In most cases, OFIS will contact you regarding the final decision within 7 business days of receiving the IRO recommendation.

In urgent situations:

If the denial seriously jeopardizes your life, health, or ability to regain maximum function, you may file for an expedited external review at the same time an expedited request is made to the health plan. OFIS will issue a decision within 72 hours. The urgency of the condition must be substantiated in writing by a licensed physician.