Consumers must first attempt to resolve disputes regarding a denial, reduction, or termination of a health care service directly with their health plan/entity through the internal grievance process of the health plan/entity. If you have completed the internal grievance process and a resolution cannot be reached through the internal grievance process, our department may review your dispute under the external review process to determine if your dispute was handled correctly under the terms of your coverage and related laws.
For more information regarding FAX or mail-in submissions please visit DIFS How to File a Complaint to download the Request for External Review form (FIS 0018).
DIFS can assist in resolving disputes under the external review process for many health insurers. However, we do not conduct external reviews for the following insurances: Non-governmental self-funded health plans, Medicare or Medicare Supplement, Worker’s Compensation, Auto, and federal employee benefit programs including military, and/or liability insurance, etc. See http://www.legislature.mi.gov/(S(sdsms1moblxcjw1lucgtaqhd))/documents/mcl/pdf/mcl-550-1905.pdf for the complete listing.
*At this time our system does not allow for the online submission of the following types of complaints: Business-to-Business, Provider Clean Claims, and Proof of Claim Against a Mortgage Company Bond.
Request For Review Eligibility
DIFS will assist in an external review if ALL the following apply:
- You have exhausted the health carrier's internal grievance process. (unless waived because the health carrier did not complete their review within the required time).
- The request is within 127 days of receipt of a final adverse determination.
- The patient was covered on the date of service.
- The health care service appears to be a covered benefit.