Michigan Laws 550.1923 – Maintenance of records; report to director
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Terms Used In Michigan Laws 550.1923
- 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 Director: means the director of the department. 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 benefit plan: means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of covered health care services. 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 Independent review organization: means a person that conducts independent external reviews of adverse determinations. 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
(1) An independent review organization assigned to conduct an external review under section 11 or 13 shall maintain for 3 years written records in the aggregate and by health carrier on all requests for external review for which it conducted an external review during a calendar year. Each independent review organization required to maintain written records on all requests for external review for which it was assigned to conduct an external review shall submit to the director, at least annually, a report in the format specified by the director.
(2) The report to the director under subsection (1) must include in the aggregate and for each health carrier all of the following:
(a) The total number of requests for external review.
(b) The number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination.
(c) The average length of time for resolution.
(d) A summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the director.
(e) The number of external reviews under section 11(13) that were terminated as the result of a reconsideration by the health carrier of its adverse determination or final adverse determination after the receipt of additional information from the covered person or the covered person‘s authorized representative.
(f) Any other information the director may request or require.
(3) A health carrier shall maintain for 3 years written records in the aggregate and for each type of health benefit plan offered by the health carrier on all requests for external review that are filed with the health carrier or that the health carrier receives notice of from the director under this act. A health carrier required to maintain written records on all requests for external review shall submit to the director, at least annually, a report in the format specified by the director.
(4) The report to the director under subsection (3) must include in the aggregate and by type of health benefit plan all of the following:
(a) The total number of requests for external review.
(b) From the number of requests for external review that are filed directly with the health carrier, the number of requests accepted for a full external review.
(c) The number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination.
(d) The average length of time for resolution.
(e) A summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the director.
(f) The number of external reviews under section 11(13) that were terminated as the result of a reconsideration by the health carrier of its adverse determination or final adverse determination after the receipt of additional information from the covered person or the covered person’s authorized representative.
(g) Any other information the director may request or require.