Michigan External Review (DIFS / PRIRA)

What is external review?

External review under Michigan's Patient's Right to Independent Review Act (PRIRA) lets DIFS assign an independent review organization (IRO)—or review contractual disputes directly—to decide whether a carrier's adverse determination was correct (MCL 550.1911).

The DIFS Director issues a written order upholding or reversing the denial. For medical-necessity cases, the IRO is not bound by the carrier's earlier decisions.

General overview: Appeals roadmap. Complete Michigan internal appeals first unless an exception applies.

Who can use Michigan review?

PRIRA external review generally applies when:

• You have a Michigan-regulated health benefit plan
• You were covered on the date of service
• The service appears to be a covered benefit
• The dispute involves medical necessity, clinical review criteria, experimental/investigational treatment, or certain contractual issues
• You exhausted internal grievance (or qualify to skip it)

Usually does not apply to:

• Self-funded ERISA employer plans
• Medicaid (MCO appeal and MOAHR fair hearing)
• Medicare

Deadlines & exhaustion

127-day filing window (DIFS)

DIFS requires external review requests within 127 days of a final adverse determination after internal appeal (DIFS — appealing). The statute provides not later than 120 days (MCL 550.1911(1))—follow the deadline on your notice or confirm with DIFS.

Exhaust internal grievance first

Normally complete the carrier's internal process (MCL 550.1907(2)), unless:

• The carrier missed required internal appeal deadlines
• You filed expedited internal grievance and may file expedited external review when medically justified

How to file

1. Complete internal appeal and keep the final adverse determination letter.
2. Gather medical records, denial letters, and a written explanation of why you disagree.
3. Submit to DIFS:
   • DIFS online external review (PRIRA)
   • DIFS — appealing a health insurer decision (paper forms)
4. For experimental/investigational denials, include treating-provider certification (form FIS 2326 per DIFS).
5. Authorized representatives should include form FIS 0018.

Questions: DIFS 877-999-6442.

How long it takes

• DIFS preliminary review: often within 5 business days of receiving your request (MCL 550.1911(2))
• Standard: IRO recommendation within 14 daysof assignment; Director's decision within 7 business days after receiving the recommendation
• Expedited: IRO recommendation within 36 hours; Director's decision within 24 hours after recommendation; must file within 10 daysof carrier's final decision and include physician substantiation; preservice only (MCL 550.1913)
• DIFS consumer materials describe expedited external review within 72 hours overall

Is the decision binding?

The Director's order is binding on the carrier, which must immediately approve coverage if the denial is reversed ( MCL 550.1911(19)). You may seek judicial review in circuit court within 60 days under MCL 550.1915 if you remain aggrieved.

For ongoing insurer conduct issues, see Regulator complaints.

Medicaid & Medicare

Medicaid

Medicaid managed care uses MCO appeals and MOAHR fair hearings—not PRIRA (MDHHS — Medicaid hearings).

Medicare

Use Medicare appeal levels—see Medicare appeals.