What is an internal appeal?
An internal appeal—often called a grievance—asks the health carrier to reconsider its adverse determination about coverage, payment, or prior authorization.
This is different from external review, where DIFS administers independent review under the Patient's Right to Independent Review Act (PRIRA) after internal appeal is complete (with exceptions).
General walkthrough: Appeals roadmap. Michigan specifics below.
Michigan appeal timelines
Carriers must provide written notice of internal and external review rights when they send an adverse determination (MCL 550.1907). DIFS consumer guidance states:
- Preservice denials: carrier internal review often within 30 calendar days
- Post-service denials: often within 60 calendar days
- Federal Affordable Care Act timelines also apply to many plans
If the carrier is late
If the carrier does not issue a written decision within the required time (and you did not agree to a delay), you may file for external review with DIFS and are treated as having exhausted internal grievance (MCL 550.1907(2)(i)).
Expedited internal grievance
When delay would seriously jeopardize life, health, or ability to regain maximum function (physician substantiation), you may file an expedited internal grievance and, in some cases, simultaneous expedited external review ( MCL 550.1907(2)(i), 550.1913).
How to file
- Read the adverse determination for the appeal deadline and required format.
- Submit a written appeal to the carrier with supporting medical records and a provider letter.
- Request expedited review if urgent harm is likely.
- Keep copies of everything submitted and the date sent.
Carrier links: Michigan prior auth & internal appeals links.
Evidence that helps
- Treating provider letter on medical necessity
- Clinical records and the carrier's clinical review criteria
- Peer-reviewed literature for experimental/investigational disputes
Medicaid appeals
Medicaid managed care members must exhaust the MCO internal appeal before a state fair hearing with MOAHR (MOAHR — public assistance hearings). Use form MDHHS-5617 for state fair hearing requests—often within 120 days of the MCO appeal resolution.
Eligibility-only MDHHS decisions may use different forms and deadlines (see MDHHS appeal guidance)—follow your notice.
After internal appeal
If the carrier upholds denial, keep the final adverse determination letter with PRIRA external review instructions.
Next step: Michigan external review (DIFS).