Michigan Laws 550.1925 – Description of internal grievance and external review procedures; inclusion with materials provided to covered persons
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Terms Used In Michigan Laws 550.1925
- 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
- Covered 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
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- 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
(1) A health carrier shall include a description of the internal grievance and external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to covered persons.
(2) The description under subsection (1) must include all of the following:
(a) A statement informing the covered person of his or her right to file a request for an internal grievance and external review of an adverse determination.
(b) The director‘s toll-free telephone number and address.
(c) A statement informing the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records that may be required to be reviewed to reach a decision on the external review.