Mich. Admin. Code R. 500.64 - Determinations by an insurer or the association
Rule 64.
(1) If,
after reviewing a providers written explanation provided under part 2 of these
rules, an insurer or the association determines that a provider overutilized or
otherwise rendered or ordered inappropriate treatment, training, products,
services, or accommodations, or that the cost of the treatment, training,
products, services, or accommodations was inappropriate under chapter 31 of the
act , MCL 500.3101 to 500.3179, the insurer or the association must issue a
written notice of the determination to a provider within 30 days of receipt of
the providers written explanation. The notice must include all of the
following:
(a) The criteria or standards on
which the insurer relied in making its determination, with specific reference
to the insurers utilization review program.
(b) The amount of payment to the provider
that has been made as a result of the determination, including an explanation
for the difference between that amount and the amount billed by the
provider .
(c) If applicable, a
description of any additional records the provider must submit to the insurer
in order for the insurer or the association to reconsider its
determination.
(d) A copy of the
form referenced in R 500.65(1).
(e)
The date of the determination.
(2) The associations determination may be
used by an insurer as the criteria or standards identified in an insurers
written notice described in subrule (1) of this rule.
(3) An insurers or the associations denial of
a providers bill on the basis that the provider overutilized or otherwise
rendered or ordered inappropriate treatment, training, products, services, or
accommodations, or that the cost of the treatment, training, products,
services, or accommodations was inappropriate under chapter 31 of the act , MCL
500.3101 to 500.3179, is a determination from which a provider may appeal to
the department under R 500.65, regardless of whether the insurer has requested
a written explanation from the provider under this rule.
Notes
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