Mich. Admin. Code 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.
Notes
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