Michigan Prior Authorization Law: What Employers Need to Know
What the 2022 prior authorization reforms require of insurers, what changed for providers, and how self-funded plans differ.
What The Law Does
Michigan reformed how insurers handle prior authorization requests.
Public Act 60 Of 2022
Signed in April 2022, the law reformed prior authorization for commercial health insurance. The practical effect is that insurers and providers follow set rules for how approvals are requested and answered. Employers can use the law as a reference point when talking with carriers about how authorization works in their plans.
Fully In Effect June 2023
All provisions were in effect as of June 1, 2023. Because every provision is now in force, employers do not need to wait for further phase-in dates. Ask your carrier how its current prior authorization process reflects the law and whether anything has changed since your last renewal.
Who It Covers
Commercial policies regulated by the state insurance department, and the insurers, their vendors and the providers involved. The reach extends beyond insurers to the vendors they hire to manage utilization review and to the providers who request approvals. If your plan is fully insured, ask the carrier which vendors handle these decisions and how they are overseen.
Who It Does Not Cover
It does not apply to Medicaid, Medicare, Medicare Advantage or self-funded plans. Because self-funded plans sit outside the state law, employers with that structure should talk to their administrator about the standards they follow. Counsel can explain which rules apply and where the plan sets its own policies.
Why Employers Care
Authorization rules shape claim denials, delays and employee frustration. Delays in approval can leave an employee unsure whether a treatment will be covered, which often ends up as calls to HR. Knowing the rules helps you answer questions and press the carrier when something seems off.
General Information
This is a summary, not legal advice. Employers should ask counsel how the law applies to their particular plan, since coverage type, funding method and plan documents all matter. Use this page to prepare questions for that conversation and for carrier meetings.
Online Submission Is Required
Faxes no longer count.
Insurers Must Offer An Online Method
Insurers must provide an online way to submit prior authorization requests. This requirement is meant to speed up the process and make it easier to track a request. Ask the carrier what the portal looks like in practice and how providers and employees can follow the status of a request.
Facsimiles Do Not Count
A fax is not an acceptable submission method. The rule pushes the process toward electronic channels that can be tracked and timed. Employers can ask whether any older fax-based steps remain in their carrier’s process, since delays there may be a source of employee complaints.
Providers Submit Electronically
Clinicians must submit requests electronically except during a temporary technology or power failure. The exception for outages is narrow and temporary, so routine reliance on paper or phone requests is not what the law contemplates. HR can pass along that expectation when helping employees whose providers are slow to submit.
The Clock Resets
When an insurer asks for more information, the review clock restarts when the information arrives. Because a request for more information restarts the timeline, a carrier can lengthen a review by asking follow-up questions. Employers can ask how often this happens and how the carrier keeps those requests specific and necessary.
Faster Answers For Members
The goal is fewer delays in getting care approved. For employees, a faster answer means less time waiting with a treatment on hold, and fewer stressful calls to the carrier or to HR. Employers can track how often their plan hears complaints about delays and raise concerns at renewal.
How Fast An Insurer Must Respond
If the insurer misses the deadline, the request is treated as granted.
Urgent Requests: 72 Hours
A request certified as urgent by the provider is deemed granted if the insurer does not act within 72 hours of submission. Providers need to mark a request as urgent for the shorter window to apply, so employees benefit when they ask their doctor’s office to confirm that designation. HR can explain this step when staff are facing time-sensitive care.
Non-Urgent Requests: 7 Days
A non-urgent request is deemed granted if the insurer does not act within 7 calendar days. The window was 9 calendar days from June 1, 2023 through May 31, 2024. Employers should know which window applied to a request depending on when it was submitted, which can matter when reviewing older complaints. A carrier or counsel can confirm how the deemed-granted rule works for any specific case.
Missing Information
When the insurer asks for more information, the same windows run from the date the additional information is submitted. This means the clock does not simply run while the insurer waits for records, but it also gives the insurer a path to obtain what it needs. Employees can help by making sure their providers respond quickly to any request.
Approvals Last At Least 60 Days
A granted request is valid for not less than 60 calendar days, or for a clinically appropriate duration if that is longer. A longer approval period gives employees time to schedule care without risking a lapse, though plan terms and eligibility still apply. Encourage employees to confirm the approval dates in writing and to ask the provider’s office about scheduling.
Electronic Process Only
Since June 1, 2023, prior authorization must use the standard electronic process, except during a temporary technology or electrical failure. Employers can ask the carrier how it measures compliance with this requirement and how it handles the rare cases where a system outage prevents electronic submission, so that employees are not caught between the two processes.
The Statute
The Act amended MCL 500.2212c and added section 2212e to the Insurance Code. These citations are useful starting points when you want counsel or a carrier to point to specific language. Reading the statute itself is better than relying on summaries, since details such as definitions and exceptions matter.
Fewer Hurdles For Providers Who Follow Guidelines
A program that relaxes some requirements.
What It Is
Insurers must adopt a program that modifies certain prior authorization requirements for clinicians who follow nationally recognized, evidence-based and quality guidelines. The requirement is meant to reward providers who consistently follow accepted clinical standards by easing the paperwork they face. Employers should ask how the carrier decides who qualifies and how often that status is reviewed.
Why It Matters
Providers with a track record face fewer approvals to obtain. Fewer approvals can mean faster care for employees who see those providers, although it does not change what the plan covers. Employers can ask whether the program reaches the doctors and facilities their employees use most often.
Carrier Programs Differ
Each carrier designs its own program within the law. One carrier may limit the program to certain specialties or procedures, while another applies it more broadly. Ask your carrier for a short written description and compare it against the provider networks your employees actually rely on.
Ask Your Carrier
Ask how the carrier’s gold card program works for your network. Request the eligibility criteria, the services covered by the program, how providers are notified and how status can be lost. Having those answers lets HR respond when an employee asks why one provider seems to face fewer hurdles.
Clinical Criteria, Reviewers And Reporting
Rules meant to make decisions understandable.
Evidence-Based Criteria
Prior authorization criteria must be evidence-based, peer-reviewed, publicly available free of charge and reviewed at least annually. Employers can ask where the carrier posts its criteria and how updates are communicated to providers. Open access to the standards helps employees and clinicians understand why a request is approved or denied, and supports any appeal.
Physician Review
Adverse decisions on non-pharmacy requests must be made by a licensed physician. This means a clinician with appropriate training, not an automated process alone, must be responsible for an adverse medical decision. Employers can ask their carrier how reviewers are assigned and how an employee can request more information about who made a decision.
Appeals
Appeals generally require review by a board-certified physician in the same specialty, with exceptions. Employees who disagree with a denial should keep the notice, note every deadline and ask their provider to support the appeal. HR can help by pointing them to the carrier’s appeal instructions and encouraging them to act promptly.
Denial Notices
Denial notices must state the reasons, the supporting criteria and the appeal process. A clear notice helps an employee and their doctor decide whether to appeal and what evidence to add. Employers who see vague letters from a carrier can raise the issue and ask for corrections at renewal.
Public Posting
Insurers must publicly post their prior authorization requirements. Public posting means employees, providers and HR can look up the requirements before scheduling a service. Employers can use these postings to check what applies to a treatment, and to prepare employees who are about to seek care.
Annual Reports
Insurers submit annual reports, and the state posts aggregated data by October 1 each year. Aggregate reports give a high-level look at how prior authorization works across the market, though they are not specific to your group. Employers can use them as background when asking their carrier about approval and denial patterns.
Insured Versus Self-Funded
State insurance law stops at self-funded plans.
Insured Plans
Fully insured group plans regulated in Michigan are covered. If your group buys a fully insured policy from a carrier licensed in the state, the law is part of the framework your plan operates in. Ask your carrier how it applies the rules to your policy.
Self-Funded Plans
Self-funded plans are not covered by the state law. Their rules come from the plan document and the administrator. Employers who self-fund should review their plan document and their administrator’s procedures so they know what employees can expect. Counsel and the administrator can explain whether the plan chooses to follow similar standards voluntarily.
Federal Rules
Federal rules on claims and appeals apply to most group health plans. Federal requirements address how claims are decided, how long decisions take and what appeal rights employees have. They apply regardless of funding type for most plans, so employers should confirm with counsel how those rules apply to their plan.
Ask Your Administrator
A self-funded employer should ask how its administrator handles authorization requests. Questions to raise include response times, the use of clinical criteria, who reviews denials and how appeals are handled. Getting those answers in writing gives HR something concrete to share with employees and to revisit at each renewal.
Verify Your Funding
Confirm whether your plan is insured or self-funded before relying on the law. Your plan documents or a quick call to the carrier or administrator will settle this. The answer affects which rules apply to prior authorization, claims and appeals, so confirm it first and keep the answer on file for reference.
What Employers Can Do
Practical steps for plan sponsors.
Review The Authorization List
Ask which services require authorization and compare carriers. Compare the list of services needing approval across carriers during a market review, since a long list creates more friction for employees and providers. Ask which items are most often delayed or denied for groups like yours.
Ask About Turnaround
Ask how long decisions take and how often they are overturned on appeal. Speed and overturn rates together say a lot about how a carrier runs its process. A carrier may not share every figure, but asking the question shows you pay attention and often leads to a useful conversation.
Help Employees Navigate
Give employees a clear point of contact for authorization problems. A named person in HR, along with instructions on what to gather and whom to call, saves employees from bouncing between the provider, carrier and employer. Keep the contact information current and include it in enrollment materials.
Track Complaints
Patterns in complaints can point to a plan or network problem. Keep a simple log of the kind of service, the carrier and how long the matter took to resolve. Reviewing it quarterly can show whether problems come from a single provider group, a specific type of service or a wider issue.
Revisit At Renewal
Include authorization practices in the renewal review. Add questions about turnaround, denial reasons, appeals and complaint trends to your renewal checklist, and compare the carrier’s answers year over year. Doing so keeps authorization from becoming a hidden source of employee frustration and lost time.
What Employers Ask About Prior Authorization
Short answers to common questions.
Does the law apply to our self-funded plan?
No. The law applies to commercial policies regulated by the state, not self-funded plans.
Can a provider still fax a request?
Faxes are not an acceptable method. Requests are submitted electronically except during a temporary outage.
What is gold carding?
A program that eases certain requirements for clinicians who follow evidence-based guidelines.
Who decides a denial?
A licensed physician must make adverse decisions on non-pharmacy requests.
Can members appeal?
Yes. Denial notices must explain how.
Is the clinical criteria public?
Yes. It must be publicly available free of charge and reviewed annually.
Does the law set response deadlines?
Yes. A request certified as urgent is deemed granted if the insurer does not act within 72 hours. A non-urgent request is deemed granted after 7 calendar days, which was 9 days through May 31, 2024.
Who should we ask?
Your carrier and benefits advisor.
Related Guides
Related reading: Michigan benefits compliance · Mental health parity · Oral chemotherapy law · Group health insurance
The rules in one place.
Michigan Employer Benefit Laws
Wages, sick time, civil rights and coverage mandates, in one place.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
An independent employee benefits consulting firm. We look at the entire benefits program — cost, plan performance, risk and administration.
Switch to CFH. Unhappy with your broker? Your employees won’t notice. You will. →
Cookies on This Site
We use cookies to keep the site working properly and to understand how it is used. You can decline anything that is not essential. See our Privacy Policy for the detail.
- Essential — needed for the site to load and for you to move around it. These cannot be switched off.
- Analytics — tell us which pages get read, so we know what is worth writing more of.
- Advertising — set by third parties such as ad and social platforms to measure and target campaigns.