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State guide

Michigan

Pick the kind of plan you have to see who to call first. Michigan can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

The short version for Michigan

Michigan's outside review is a free appeal filed directly with the Department of Insurance and Financial Services under the Patient's Right to Independent Review Act. You have 127 days after the insurer's final denial, and the Department's director can also decide purely contractual disputes (such as whether something is a covered benefit), not only medical necessity. Department staff will walk you through it by phone.

At a glance: independent review for plans Michigan regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
Michigan Department of Insurance and Financial Services (DIFS) · 877-999-6442
Independent review
A state process (External appeal (external review) under the Patient's Right to Independent Review Act (PRIRA))
Deadline to request it
127 days after you receive the insurer's final decision (final adverse determination)
Cost
none
Decision time
No single number is published on the consumer page. By statute the independent review organization has 14 days after assignment to give its recommendation and the Director has 7 business days after that to decide.; fast track: 72 hours

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

Independent (external) review

Process
A state process. Run by Michigan Department of Insurance and Financial Services; medical questions are assigned to an independent review organization and the Director issues the decision.
Where you file
regulator
How
File the online Health Care Appeals - Request for External Review form, or send the paper form (FIS 0018) by email (DIFS-HealthAppeal@michigan.gov), fax (517-284-8838) or mail. Include a copy of the insurer's final denial, your reasons, and supporting documents such as medical records (the Department does not collect them for you). Call 877-999-6442 for help.
Which denials qualify
A denial, reduction or termination of a health care service that appears to be a covered benefit, where the patient was covered on the date of service. Medical questions go to an independent review organization; purely contractual questions can be decided by the Director. Medicare supplement, disability income, hospital indemnity, specified accident, credit, long term care and non-governmental self-funded plans are not eligible.
Appeal to the plan first?
Yes, unless the insurer did not finish its internal review in time (30 days for care not yet received, 60 days for care already received). An expedited external appeal requires that you asked the plan for an expedited appeal, that the Department receives your request within 10 days of the plan's decision, a letter from your treating physician, and that the care has not yet been received.

Official page Request form

General rules and what to send: how external review works, how to request it.

Free help in Michigan

Medicare and Medicaid in Michigan

Medicare counseling
Michigan State Health Insurance Assistance Program (SHIP) · 1-800-803-7174 . Free help with Medicare appeals.
Medicaid agency
Michigan Department of Health and Human Services (Michigan Medicaid); hearings are held by the Michigan Office of Administrative Hearings and Rules
Fair hearing deadline
90 days from the date the notice was mailed for actions not taken by a managed care plan; 120 days from the date of the plan's Notice of Resolution if you are in a managed care plan. Your notice states the deadline that applies to you.
Good to know
If a Medicaid health plan made the decision, you must go through the plan's internal appeal first; if the plan does not answer within 30 days (44 with an extension) you can ask for a State Fair Hearing. To keep benefits you already receive, ask before the date the notice says they will change or stop. Hearing forms and help: Beneficiary Help Line 1-800-642-3195.

Medicaid appeals page How Medicaid appeals work

State laws that can help

  • External review. The Patient's Right to Independent Review Act gives you an external review by the state, with the review organization's recommendation due within 14 days of assignment and the Director's decision within 7 business days after that.

    Michigan Compiled Laws 550.1911 (Public Act 251 of 2000)

  • Prior authorization. A prior authorization request is considered granted if the insurer does not act within 7 calendar days (72 hours if your provider certifies it as urgent), and an approval is valid for at least 60 calendar days.

    Michigan Compiled Laws 500.2212e (Public Act 60 of 2022)

  • Mental health parity. Health insurers must cover mental health and substance use disorder services with cost sharing and treatment limits (including prior authorization rules) no more restrictive than those for medical and surgical care.

    Michigan Compiled Laws 500.3406hh (Public Act 41 of 2024)

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Appealing a Decision Made by Your Health Insurer (DIFS)
  2. DIFS Online Health External Review Form (PRIRA)
  3. Health Care - Request for External Review (FIS 0018)
  4. DIFS press release, June 29, 2026: right to appeal denied health insurance claims
  5. Filing a Complaint with DIFS
  6. Michigan Compiled Laws 550.1911
  7. State Health Insurance Assistance Program (Michigan Department of Health and Human Services)
  8. Medicaid Fair Hearings (Michigan Department of Health and Human Services)
  9. Michigan Office of Administrative Hearings and Rules Medicaid hearing brochure
  10. CMS: State External Appeals Review Processes
Not confirmed (6)
  • The deadline to request independent review. the Department's pages and forms all say 127 days, but the statute (MCL 550.1911) says 120 days after receipt of the notice; the Department's figure is used
  • How long a standard independent review takes. the consumer page gives no overall number of days; the statutory steps are shown instead
  • How to tell whether the state regulates your plan. no official Michigan tip found for telling a state-regulated plan from a self-funded one
  • A searchable list of past decisions. the Department issues written orders under the Act, but a searchable page of past orders was not confirmed
  • Free consumer help programs. the federal directory lists Michigan as having a Consumer Assistance Program; no separate program page could be loaded, so the Department's consumer office is listed
  • State laws that help. no Michigan step therapy or surprise billing statute was verified on an official page, so none is listed

Sources last checked . Found a mistake? Report it.