Mich. Admin. Code R. 500.66

Current through Vol. 24-21, December 1, 2024

Section R. 500.66 - Required components of an insurers utilization review program

Rule 66.

(1) Within 60 days of the effective date of these rules, insurers must have in place a utilization review program to review records and bills for treatment, training, products, services, and accommodations provided to an injured person that is above the usual range of utilization based on medically accepted standards.

(2) The utilization review program must do all of the following:

(a) Provide for bill review, including whether provider charges for treatment, training, products, services, and accommodations comply with chapter 31 of the act, MCL 500.3101 to 500.3179, and rules promulgated thereunder.

(b) Make determinations regarding the appropriateness of treatment, training, products, services, and accommodations based on medically accepted standards.

(c) Issue determinations under R 500.64.

(3) Insurers must submit information regarding their utilization review program to the director annually on a form prescribed by the department.

(4) No later than 90 days after the submission of the information required under subrule (3) of this rule, the director shall issue a certification of the insurers utilization review program. Certification shall be either unconditional or conditional. The director may extend the time for review by an additional 30 days upon written notice to the insurer.

(5) The director may issue unconditional certification for a period of 3 years.

(6) The director may issue conditional certification if it determines that the insurer or other entity does not substantially satisfy the criteria in subrule (2) of this rule. If the insurer agrees to undertake corrective action, then conditional certification shall be granted by the department for a maximum period of 1 year.

(7) The director may at any time modify an unconditional certification to a conditional certification if the director determines that an insurer has failed to comply with any of these rules. The director shall provide written notice to the insurer in the event of such a modification. The unconditional certification shall be reinstated upon satisfactory completion of a corrective action plan developed by the insurer and approved by the director.

(8) The director may revoke a certification upon a finding that an insurer has failed to comply with any of the rules and has failed to satisfactorily complete a corrective action plan. The director shall provide written notice to an insurer upon revocation.

Mich. Admin. Code R. 500.66

2020 MR 24, Eff. 12/18/2020