Michigan Laws 550.1915 – Decision as final administrative remedy; other remedies
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(1) An external review decision and an expedited external review decision are the final administrative remedies available under this act. A person aggrieved by an external review decision or an expedited external review decision may seek judicial review no later than 60 days from the date of the decision in the circuit court for the county where the covered person resides or in the circuit court of Ingham county.
(2) Subsection (1) does not preclude a health carrier from seeking other remedies available under applicable state law.
Terms Used In Michigan Laws 550.1915
- Adverse determination: means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based on the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. See Michigan Laws 550.1903
- Authorized representative: means any of the following:
(i) A person to whom a covered person has given express written consent to represent the covered person in an external review. See Michigan Laws 550.1903Covered person: means a policyholder, subscriber, member, enrollee, or other individual participating in a health benefit plan. See Michigan Laws 550.1903 Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier's internal grievance process procedures as set forth in section 2213 of the insurance code of 1956, 1956 PA 218, MCL 500. See Michigan Laws 550.1903 Health carrier: means a person that is subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the director, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit health care corporation, a nonprofit dental care corporation operating under 1963 PA 125, MCL 550. See Michigan Laws 550.1903 Person: means an individual or a corporation, partnership, association, joint venture, joint stock company, trust, unincorporated organization, or similar entity, or any combination of these. See Michigan Laws 550.1903 state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories belonging to the United States; and the words "United States" shall be construed to include the district and territories. See Michigan Laws 8.3o
(3) Subsection (1) does not preclude a covered person from seeking other remedies available under applicable federal or state law.
(4) A covered person or the covered person’s authorized representative may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision under this act.