How do I start the internal grievance process?
The first step in the internal grievance process is to provide your health carrier with a written grievance, which consists of your written statements regarding the facts of the issue and your position. Your health carrier is required to provide you with the address to submit the written grievance and any special forms, as well as information on how to begin the internal grievance process. After you submit the written grievance to your health carrier, your health carrier is required to notify you of its determination in writing and to advise you of your right to the next step in the grievance process if you disagree with the determination.

What is the next step in the internal grievance process?
The next step in the internal grievance process gives the person the right to appear before the board of directors or designated committee or the right to a managerial-level conference to further pursue the grievance. After this step, your health carrier is required to notify you of its determination in writing and to advise you of your right to an external review under the Patient’s Right to Independent Review Act.

What is the Patient’s Right to Independent Review Act (PRIRA)?
The Patient’s Right to Independent Review Act is a Michigan statute that provides patients with appeal rights due to decisions made by health carriers regarding denial, reduction or termination of health care services. PRIRA applies after the patient has exhausted the health carrier’s internal grievance process. The PRIRA process is also called a PRIRA external review or PRIRA appeal. The PRIRA process does not apply to a medical provider’s complaint concerning claims payment, handling or reimbursement for health care services. Patient's Right to Independent Review act: http://www.legislature.mi.gov/mileg.asp?page=getObject&objName=mcl-Act-251-of-2000.

What kind of health coverage is subject to PRIRA?
Health coverage provided by health insurance companies, health maintenance organizations (HMOs), Alternative Finance and Delivery Systems (AFDS) and Blue Cross Blue Shield of Michigan (BCBSM) are eligible for the PRIRA review process.

What kind of health coverage is not eligible for review under PRIRA?
Insurance coverage such as Medicare supplement (Medigap) policies, disability income, hospital indemnity, specified accident or accident-only, credit insurance, self-funded health care plans (even when administered by a health carrier subject to PRIRA), the federal employee health benefit program, worker’s compensation or similar insurance, automobile medical-payment insurance or long term care plans are not eligible for review under the PRIRA process. You may still file a complaint with OFIS regarding your problems with these types of policies. How to file a complaint information is available at this link: http://www.michigan.gov/documents/cis_ofis_comp_all_25074_7.pdf.

If you have a question regarding your eligibility for the PRIRA process, you may obtain information from your health carrier or you may contact OFIS directly at 1-877-999-6442.

What is an adverse determination?
An adverse determination is a decision by a health carrier that denies a health care service, reduces coverage for a health care service or terminates coverage for a health care service. Failure to make a timely decision in response to a request for a determination is also considered an adverse determination. When a health carrier issues an adverse determination, it is required to advise you in writing of the reason for the determination and it must advise you of your rights to appeal.

What kinds of issues are subject to review by OFIS under PRIRA?
PRIRA applies to issues involving adverse determinations of health care services. The issues can involve contract language or medical necessity issues or the dollar amount paid for a health care service.

What issues are not subject to review by OFIS under PRIRA?
PRIRA does not apply to issues involving termination or cancellation of your contract/policy or the dollar amount you pay for your coverage. These issues can be handled as a regular complaint through OFIS.

Further information on how to file a complaint is available at http://www.michigan.gov/documents/cis_ofis_comp_all_25074_7.pdf.

What information is required to request a PRIRA external review through OFIS?
You must complete the Health Care – Request for External Review Form, http://www.michigan.gov/documents/cis_ofis_fis_0018_25078_7.pdf. You must also include the final adverse determination from the health carrier. Your request should be submitted within 60 days after you have received the health carrier’s final adverse determination. You should also provide documentation to support your position.

How do I appoint someone to represent me in the internal grievance process or the PRIRA process?
Michigan statutes provide that you may authorize in writing any person such as your doctor, attorney, parent or spouse to represent you in the internal grievance process and/or the PRIRA process. In the PRIRA process, this person is called an authorized representative and can be a person authorized by law to represent the patient or a family member of the patient or the patient’s doctor. The Health Care Request for External Review Form provides space to authorize a representative.

Do I need to hire an attorney to go through the PRIRA process?
No, you are not required to have an attorney represent you through the PRIRA process.

What happens after I submit a request for a PRIRA external review to OFIS?
OFIS has 5 business days to do a preliminary review to determine if you are eligible for the PRIRA external review process. OFIS notifies your health carrier of your request and obtains pertinent information to help decide if you are eligible for a PRIRA external review. OFIS makes sure your request meets the following requirements:

• The issue must involve an adverse determination
• The coverage involved must be subject to PRIRA
• The patient must have been a covered person at the time the health care service was provided or requested
• The health care service in question must reasonably appear to be a covered service under the contract/policy
• The covered person must have exhausted the internal grievance process of the health carrier

OFIS will notify you in writing if your request is accepted or not accepted for PRIRA external review. Occasionally requests are determined to be incomplete in which case we advise you of the information needed to make your request complete. If your request is not accepted, OFIS will explain why your request does not qualify under PRIRA.

If your request is accepted and involves only contractual provisions of the contract/policy, the review is conducted by the commissioner. If your request is accepted and involves issues of medical necessity or clinical review criteria, it is referred to an independent review organization (IRO).

What is an Independent Review Organization (IRO)?
An IRO is an entity that has a contract with OFIS to conduct medical reviews under PRIRA. Those reviewing the issues have medical expertise in the health care service at issue in the review.

Does OFIS investigate and obtain the patient’s medical records?
No, OFIS staff will not investigate, contact medical sources or seek out information to support the patient’s position. It is the patient’s responsibility to provide the pertinent documents such as bills, explanations of benefits, medical records, correspondence, statements from doctors and research material to support their position. If the review is referred to an IRO, the health carrier is required to provide the IRO with the medical records and other documents it used in making its determination.

When can I expect a decision from the commissioner?
If the review is conducted by the commissioner and does not require review by an IRO, the statute requires that the commissioner issue a decision within 14 calendar days after the request is accepted for review. If the review requires referral to an IRO, the IRO is required to provide OFIS with its recommendation within 14 calendar days after it is assigned the review. The statute requires that the commissioner issue a decision within 7 business days after it receives the recommendation of the IRO.

What are my rights if I disagree with a decision by the commissioner?
If you or the health carrier disagrees with the commissioner’s decision, either party has the right to appeal to circuit court in the county where the covered person resides or in Ingham County within 60 days from the date of the decision.

If the Commissioner decides to overturn the health carrier’s adverse determination through the PRIRA process and the health carrier appeals to circuit court, will OFIS represent me in circuit court?
No.

What is a PRIRA EXPEDITED external review and how does one qualify for a PRIRA EXPEDITED external review?
A PRIRA EXPEDITED external review is a faster review process available when an adverse determination (denial) involves a medical condition for which the time frame for completion of a PRIRA external review would seriously jeopardize the life or health of the covered person or would jeopardize the person’s ability to regain maximum function. A PRIRA EXPEDITED external review is completed within 72 hours after your written request has been submitted.

To qualify for a PRIRA EXPEDITED external review, the covered person must have a physician verify, orally or in writing, that the time frame for a PRIRA external review would seriously jeopardize the life or health of the covered person. A PRIRA EXPEDITED external review is only granted when the issue involves health care services that have not already been provided to the covered person.

A Request for External Review Form can be found at http://www.michigan.gov/documents/cis_ofis_fis_0018_25078_7.pdf.