What utilization review is
MCL 500.3157a, added in 2019, sets up utilization review for treatment provided after July 1, 2020. Anyone who treats a person covered by PIP is deemed to agree to submit necessary records for review and to comply with DIFS decisions. Utilization review means the insurer’s initial evaluation of whether the level and quality of care are appropriate under medically accepted standards. Knowingly submitting false or misleading records is a fraudulent insurance act.
The procedures are in Mich Admin Code R 500.61 to 500.69. Insurers must run a utilization review program certified by DIFS. Utilization review is separate from the fee schedule, but cost disputes under the schedule go through the same appeal.
The timeline, step by step
| Step | Deadline | Rule |
|---|---|---|
| Insurer asks you to explain care that is unusual in type, frequency or duration | Within 30 days after it receives your bill | R 500.63 |
| You respond with a written explanation | Within 30 days after you receive the request | R 500.63 |
| Insurer sends its written determination | Within 30 days after it receives your explanation | R 500.64 |
| You file an appeal with DIFS | Within 90 days of the determination | R 500.65 |
| DIFS sends a notice of appeal to the insurer | Within 14 days of receiving the appeal | R 500.65 |
| Insurer may file a reply | Within 21 days after the notice | R 500.65 |
| DIFS decides | Within 28 days after the reply, extendable by 28 days | R 500.65 |
| Insurer proves compliance if reversed | Within 21 days of the order | DIFS appeal procedure |
If the insurer asks for records beyond what normally accompanies a bill, R 500.63 requires it to pay a reasonable fee plus copying and mailing costs within 30 days.
What the insurer’s notice must contain
Under R 500.64, a determination of overutilization, inappropriate treatment or inappropriate cost must state the criteria relied on with reference to the insurer’s utilization review program, the amount paid and why it differs from the bill, any records needed to reconsider, a copy of the DIFS appeal form and the date of the determination. A denial that skips these items is weaker on appeal and in court. Keep every page.
Filing the appeal
Use form FIS 2356, Auto Insurance Utilization Review Provider Appeal Request. DIFS takes appeals by email to DIFS-URAppeals@michigan.gov as PDF, Word or Excel attachments, or by mail. It no longer accepts faxes. DIFS decides on the record filed with the appeal and will not accept more documents later.
- Medical necessity disputes: the form, a detailed narrative, every page of the determination, the claim form, and supporting medical records.
- Cost disputes for crashes on or after June 11, 2019: the same items plus your charge description master in effect on January 1, 2019 (or your average charge if you had none) and the FIS 2376 provider attestation.
- Home health aide and skilled nursing rates: under Bulletin 2026-15-INS, the documented Medicare rate or the data needed to run the CMS Home Health PPS Web Pricer. See home care and attendant care agencies.
List procedure codes, not diagnosis codes. Use date ranges only if service was provided on every date in the range.
What DIFS will not decide
DIFS lists matters outside the appeal process: billing and coding errors, disputes already in PIP litigation, dates of service not on the determination, cases with no written determination, coordination of benefits and coverage disputes, and accidents not reported within one year. Those go to the insurer or to court.
Appeal, sue, or both
The appeal is optional. The Court of Appeals held in True Care Physical Therapy v. Auto Club Group (May 2023) that a provider can sue under MCL 500.3112 without first appealing, and Pro-Line Physical Therapy v. MEEMIC (June 2024) held that MCL 500.3157a(5) does not strip the circuit court of jurisdiction. Once a dispute is in litigation, DIFS will not take it.
| Factor | DIFS appeal | Lawsuit |
|---|---|---|
| Cost | Low, no filing fee | Higher, but MCL 500.3148 fees may shift to the insurer |
| Record | Paper only, fixed at filing | Discovery, depositions, treating physician testimony |
| Interest | 12% under R 500.65(6) | 12% under MCL 500.3142 |
| Attorney fees | No fee-shifting provision | Available if refusal or delay was unreasonable |
| One-year-back rule | Does not stop it | Filing suit fixes the look-back date |
| Further review | Judicial review under MCL 500.244 | Appeal as of right |
A DIFS appeal suits single, well-documented denials where the fight is about a guideline or a rate. A lawsuit suits large balances, repeated denials from the same insurer, and any claim close to the one-year-back line. Litigation also opens the door to 12% interest and attorney fees, and lets you use a complete billing record as evidence.
The 90 days run from the date on the determination, not the date you opened the envelope. Calendar every utilization review denial the day it arrives.
Sources: MCL 500.3157a, 500.3142, 500.3145 and 500.3148; Mich Admin Code R 500.61 to 500.69; DIFS Utilization Review provider guidance and forms FIS 2356 and FIS 2376; DIFS Bulletin 2026-15-INS; True Care Physical Therapy, PLLC v Auto Club Group Ins Co (Mich App, May 25, 2023); Pro-Line Physical Therapy v MEEMIC Ins Co (Mich App, June 27, 2024).
Questions people ask us
How long do we have to appeal a utilization review denial to DIFS?
Ninety days from the date of the insurer’s determination, under Mich Admin Code R 500.65. DIFS does not review late appeals. Missing the deadline does not take away your right to sue, but it does take away the administrative route.
Do we have to appeal to DIFS before we can sue?
No. The Court of Appeals held in True Care Physical Therapy v Auto Club (2023) that the DIFS appeal is optional, and Pro-Line Physical Therapy v MEEMIC (2024) confirmed that a circuit court can hear a provider’s MCL 500.3112 suit even if no appeal was filed.
Can we add records after we file the DIFS appeal?
DIFS says it decides on the documents filed with the appeal and does not accept more afterward. Send the complete record the first time, including every page of the insurer’s determination.
Does DIFS award interest if we win?
Yes. R 500.65(6) provides that a provider found entitled to payment receives interest on overdue payments under MCL 500.3142, which is 12% a year.