External Review

State process

Once you have exhausted our standard internal grievance process, you or your authorized representative may request an external review. Depending on your plan, the review will be conducted by the Michigan Commissioner of Financial and Insurance Regulation or the Office of Personnel Management.

External review process for PPO and EPO members

The standard external review process is as follows:

1. Within 120 days of the date you received our final determination or should have received it, send a written request for an external review to the commissioner.
   
   • Mail your request, including the required forms that we will supply to you, to:
     Office of Financial and Insurance Regulation
     Office of General Counsel
     Health Care Appeals Section
     P.O. Box 30220
     Lansing, MI 48909-7720
     
2. If your request for external review concerns a medical issue and is otherwise found to be appropriate for external review, the commissioner will assign an independent review organization, consisting of independent clinical peer reviewers, to conduct the external review.
   • You will have an opportunity to provide additional information to the commissioner within seven days of submitting your request for an external review. We must provide documents and information considered in making our final determination to the independent review organization within seven business days after we receive notice of your request from the commissioner.
   • The assigned independent review organization will recommend within 14 days whether the commissioner should uphold or reverse our determination. The commissioner must decide within seven business days whether or not to accept the recommendation and will notify you. The commissioner's decision is the final administrative remedy under the Patient's Right to Independent Review Act of 2000.
3. If your request for external review is related to nonmedical issues and is otherwise found to be appropriate for external review, the commissioner's staff will conduct the external review.
   • The commissioner's staff will recommend whether the commissioner should uphold or reverse our determination. The commissioner will notify you of the decision, and the commissioner's decision is your final administrative remedy under Public Act 350.