Fillable AUTO INSURANCE UTILIZATION REVIEW PROVIDER APPEAL REQUEST (Michigan)

Fill Online, Printable, Fillable, Blank AUTO INSURANCE UTILIZATION REVIEW PROVIDER APPEAL REQUEST (Michigan) Form

Use Fill to complete blank online MICHIGAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

AUTO INSURANCE UTILIZATION REVIEW PROVIDER APPEAL REQUEST (Michigan)

On average this form takes 6 minutes to complete

The AUTO INSURANCE UTILIZATION REVIEW PROVIDER APPEAL REQUEST (Michigan) form is 2 pages long and contains:

  • 1 signature
  • 4 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

BROWSE MICHIGAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FIS 2356 (08/21) Department of Insurance and Financial Services Page 1 of 2
AUTO INSURANCE UTILIZATION REVIEW
PROVIDER APPEAL REQUEST
Michigan Department of Insurance and Financial Services
Office of Research, Rules, and Appeals
Utilization Review Section
DIFS-URAppeals@michigan.gov
Fax: 517-763-0305
Michigan.gov/AutoInsuranceUR
For guidance on auto insurance utilization review appeals, please reference The Health Care Provider’s
Guide to Michigan’s Auto Insurance Utilization Review Appeals Process
at www.michigan.gov/AutoInsuranceUR
.
I. PROVIDER INFORMATION
The name of the provider entered below must match the provider name listed on the insurer
determination letter or insurer bill denial.
Provider (name of physician, hospital, clinic, or other person/entity):
Provider Point of Contact:
Provider Address:
Phone Number: Fax Number:
Email Address:
II. CLAIM INFORMATION
Please include the following information related to this appeal request.
Date of Denial/Determination: Date of Accident:
Date(s) of Service:
Claim Number:
Injured Person Name and Mailing Address:
FIS 2356 (08/21) Department of Insurance and Financial Services Page 2 of 2
III. INSURER INFORMATION
Please provide the complete name and contact information of the insurer or insurance company
related to this appeal request.
Insurer Name:
Insurer Address:
IV. DOCUMENTATION REQUIRED
The following information is required. Failure to include all documentation relevant to this appeal
may result in the appeal request being rejected.
☐
A detailed narrative of the reason(s) for the appeal request.
☐
A copy of the insurer’s notice of determination or a denial of a bill per R 500.64(1)(3).
☐
All correspondence and documents related to a request for explanation exchanged
between the provider and the insurer prior to this appeal request per R 500.63.
☐
All supporting documentation related to the appeal request.
List of documentation included with appeal request (Date/Title/Number of Pages):
V. PROVIDER CERTIFICATION AND ACKNOWLEDGEMENTS
By signing this form, I understand and acknowledge that I will respond to the Michigan
Department of Insurance and Financial Services’ inquiries regarding this appeal, and I certify that
the information included on this form is correct and complete to the best of my knowledge and
belief. I also understand and acknowledge that submitting false or misleading information is
cause for rejection of the appeal and may subject me and/or the provider to penalties as
provided by law.
Authorized Signature:
Date:
Printed Name / Title:
Email Address:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

AUTO INSURANCE UTILIZATION REVIEW PROVIDER APPEAL REQUEST (Michigan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 October 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document