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New Auto No-Fault Utilization Review Rules Now in Effect

February 25, 2021

The Michigan Department of Insurance and Financial Services (DIFS) has issued final utilization review rules for providers treating auto no-fault patients, which became effective on December 18, 2020. All providers providing treatment, training, products, services and accommodations to no-fault patients after July 1, 2020 are subject to these new rules. The rules, among other things, address utilization review standards, set forth a process for insurers to request additional information from providers under certain circumstances, and include a process for providers to appeal insurer denials to DIFS

The new rules require insurers to establish utilization review programs by February 16, 2021, but all claims for auto no-fault patients for dates of service after July 1, 2020 are subject to this utilization review process. The rules allow insurers to deny auto no-fault claims when a provider over-utilized or otherwise rendered or ordered inappropriate treatment, training, products, services, or accommodations, or if the cost of the treatment, training, products, services, or accommodations was inappropriate. Many of the utilization review standards under the rules are subject to interpretation and will likely be the subject of future negotiations between providers and auto insurers. 

Jennifer Benedict and Becky Glitman, along with Sally Bailey from Michigan Medicine, presented during a webinar hosted by the Michigan Health & Hospital Association on provider considerations and strategies for these new rules. The handout from the presentation provides an overview of the appeals process and requirements and is available here.

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