Appealing a Denied ABA Claim in Michigan
The path after a denial depends on the plan type.
The appeal path
Internal appeal
The member begins with the carrier’s internal grievance. A carrier must tell the member in writing about internal and external review rights.
External review
After the internal grievance is exhausted (expedited cases excepted), the member may request external review from the DIFS director. The statute sets 120 days after receiving notice of the final decision, and the DIFS consumer page says 127 days, so file early.
Expedited review
Where delay would seriously jeopardize health or function, an expedited external review may be requested within 10 days of the adverse determination.
Complaints and courts
A person may file a complaint with DIFS. An external review decision is final administratively, with judicial review within 60 days.
Back to the ABA guide.
Appealing a Denied ABA Claim in Michigan: short answers
Does external review apply to self-funded plans?
The Act applies to health carriers, so self-funded plans follow their own claims procedure and federal ERISA rules.
What should the member include?
The denial letter, the treatment plan and the physician or psychologist’s necessity statement.
Who can help?
The carrier, DIFS at 877-999-6442 and counsel.
Appealing a Denied ABA Claim in Michigan: not legal advice. Send us your renewal.
Where these details come from
The laws and rules named on this page link to the official text. This is general information, not legal advice, and rules change, so check the current text.
DIFS: Autism Spectrum Disorder Health Coverage
Patient’s Right to Independent Review Act, Public Act 251 of 2000
MCL 550.1911, request for external review
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