Rule 62. These rules do all of the following:
(a) Establish criteria and standards for utilization review that identify utilization of
treatment, training, products, services, and accommodations provided to an injured person for the
injured person’s care, recovery, or rehabilitation as required under section 3107(1)(a) of the act,
MCL 500.3107(1)(a), above the usual range of utilization, based on medically accepted
standards.
(b) Establish procedures for all of the following:
(i) Acquisition of necessary records, medical bills, and other information concerning the
treatment, training, products, services, and accommodations provided to an injured person.
(ii) For an insurer and for the association to request an explanation for, and requiring a
provider to explain, the reasonable necessity or indication for treatment, training, products,
services, and accommodations provided to an injured person.
(iii) Provider appeals to the department from an insurer’s or the association’s
determination that the provider overutilized or otherwise rendered or ordered inappropriate
treatment, training, products, services, and accommodations, or that the cost of the treatment,
training, products, services, and accommodations was inappropriate under chapter 31 of the act,
MCL 500.3101 to 500.3179, and rules promulgated thereunder.
(c) Apply to treatment, training, products, services, and accommodations provided after
July 1, 2020, to an injured person who is insured under a policy of no-fault automobile insurance
issued under chapter 31 or chapter 31A of the act, MCL 500.3101 to 500.3179 and 500.3181 to
500.3189.
(d) Apply to all insurers providing personal protection insurance under chapter 31 of the
act, MCL 500.3101 to 500.3179 or under chapter 31A of the act, MCL 500.3181 to 500.3189,
and to the association. Nothing in these rules should be construed to limit the ability of insurers
and the catastrophic claims association to contract with a medical review organization to perform
utilization review activities on their behalf. An insurer that uses a medical review organization
remains responsible for complying with the act and any rules promulgated thereunder.
History: 2020 MR 24, Eff. Dec. 18, 2020.
PART 2. REQUESTS FOR EXPLANATION AND RECORD RETENTION
R 500.63. Requests for explanation.
Rule 63. (1) If a provider provides treatment, training, products, services, or
accommodations to an injured person that are not usually associated with, are longer in duration
than, are more frequent than, or extend over a greater number of days than the treatment,
training, products, services, or accommodations usually required for the diagnosis or condition
for which the injured person is being treated, the insurer or the association may request that the
provider explain the necessity or indication for the treatment, training, products, services, or
accommodations in writing. An insurer or the association may request that the provider include
in its written explanation medical records, bills, and other information concerning the treatment,
training, products, services, or accommodations.
(2) If an insurer or the association requests a provider to provide a written explanation under
this rule, the request must be submitted to the provider within 30 days of the insurer’s or
Page 2