Health Care Appeals – Request for External Review (FIS 0018)

Before You Begin

Consumers must first attempt to resolve disputes regarding a denial, reduction, or termination of a health care service directly with their health plan/entity through the internal grievance process of the health plan/entity. If you have completed the internal grievance process and a resolution cannot be reached through the internal grievance process, our department may review your dispute under the external review process to determine if your dispute was handled correctly under the terms of your coverage and related laws.

This online process is for patients, their parents or legal guardian to file a request for external review of an adverse determination. If you are not one of these persons, please check with the patient, parent or legal guardian to determine if they want you to act as their authorized representative and are aware you are pursuing this matter on their behalf. This process is not for providers to address their claim payment problems.

If you choose to file your request for external review online, you will need to have a valid email address and the ability to include relevant documentation as attachments. If you do not have a valid email address or the means to provide documents electronically, you must file your request for an external review by FAX or mail.

For more information regarding FAX or mail-in submissions please visit DIFS How to File a Complaint to download the Request for External Review form (FIS 0018).

DIFS can assist in resolving disputes under the external review process for many health insurers. However, we do not conduct external reviews for the following insurances: Non-governmental self-funded health plans, Medicare or Medicare Supplement, Worker’s Compensation, Auto, and federal employee benefit programs including military, and/or liability insurance, etc. See Patient's Right to Independent Review Act (Excerpt) for the complete listing.

*At this time our system does not allow for the online submission of the following types of complaints: Provider Clean Claims, and Proof of Claim Against a Mortgage Company Bond.

Request For Review Eligibility

DIFS will assist in an external review if ALL the following apply:

  • You have exhausted the health carrier's internal grievance process. (unless waived because the health carrier did not complete their review within the required time).
  • The request is within 127 days of receipt of a final adverse determination.
  • The patient was covered on the date of service.
  • The health care service appears to be a covered benefit.
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 1. Contact Information

Please provide the information below for the person to contact if we have questions regarding your request for an external review.

If the patient is a minor, the contact person should be indicated as the parent or legal guardian.

Important:  A Request for External Review (FIS 0018) form should be included with requests submitted on behalf of a patient who is 18 years of age or older. Please return the form with sections 4, 5, 6 and 7 completed.

* - Required Field
*This request is being filed by (choose one)



*What is your relationship to the patient?
Contact Name
Contact Address
Contact Methods

*You must provide at least one phone number at which you can be reached in addition to an email address.

If you have a preferred contact number, select the 'preferred number' option next to that number. If only one phone number has been entered, that is assumed to be your preferred contact number.

Home is Preferred Contact Number
Cell is Preferred Contact Number
Work is Preferred Contact Number
Patient Name
Patient Address
Patient Contact

*You must provide at least one phone number for the patient.

 2. Expedited Request

An expedited external review is only for cases where “the adverse determination involves a medical condition of the covered person for which the timeframe for completion of an expedited internal grievance would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function as substantiated by a physician either orally or in writing.”

Important: Adverse Determination means your claim or request for service was denied, reduced or terminated.

If you do not meet these criteria, please do not check the boxes indicating you are requesting an expedited review (it is not for cases where the denial is based on the terms of your insurance coverage: i.e., frequency or quantity limitations, evaluation or reimbursement levels, accuracy of coding, etc.).

The following conditions must be met in order for your request to be considered as expedited: (Check all that apply to your request)
* - Required Field
My request meets these requirements. By completing the items below, I am requesing an Expedited External Review.
Name of Substantiating Physician
 3. Health Carrier Details

In this section, you will indicate the name of the insurance company/entity that issued the adverse determination (denial) in addition to policy details for that carrier.

If more than one insurance company or entity is involved, you may add as many names of any other insurance companies or entities (i.e., third party administrators) involved with your dispute as needed.

* - Required Field

Health Carrier Details

You have not identified any health carriers.
 Add a Health Carrier

 4. Details

This section gathers additional information about your request. Although some of this information is not required, the more details you can provide, the better we will be able to assist with a resolution.

* - Required Field

Additional Details

Involved Entities

Use this section to provide the names of physicians, medical facilities or other providers involved with this request.
Enter the name of the physician, medical facility or other provider, then click 'Add This Entity' button.
You may repeat this process to add as many providers as you need.


Service Date(s)

Use this section to provide the date service was requested or dates services were recieved.
Select the type of date you want to add, enter the date(s), then click 'Add This Date' button.
You may repeat this process to add as many dates of service as you need.

Service Date Type:
Service Date Type:

*Explanation of the Problem:

Provide a brief explanation of the problem. Be sure to describe the medical service received or requested.

*Describe Your Desired Outcome:

Describe the resolution you would like to see from this review.

Attachments/Documentation:

Documentation relating to your request for external review is important. This information helps us to understand details of your request. Please attach copies of letters or other documents that will help us review your request.

  • Please limit filenames to 70 characters or less
  • MS Office, image or PDF files preferred
  • Total file upload is limited to 25MB

Examples: insurance policies, insurance ID card, bills, denial letters from the insurance company, letters of medical necessity from your physician(s), medical records, etc.

Attaching a file to your request is a three-step process.

  1. Click on the "Choose File" or "Browse" button below to browse your device for a file.
  2. Select the kind of document you are attaching using the Select a File Type dropdown
  3. Enter a description of the file and click on the "Upload" button to complete the upload.

Please note: If your attachment is over the 25 MB size limit, please send the attachment(s) to DIFS as an email referencing your confirmation number to [email protected], FAX to 1-517-284-8838, or mail through the U.S. Postal Service. Please include your confirmation number when faxing, emailing or mailing documents to DIFS. Your confirmation number is included in the request summary.

Important: 
A Request for External Review (FIS 0018) form should be included with requests submitted by an Authorized Representative. Please return the form with sections 4, 5, 6 and 7 completed.

Form FIS 2326 should be included with requests involving experimental or investigational denials. Please return the form completed and signed by your treating provider to DIFS within 30 days.

Important: 
You indicated that your situation meets criteria for an expedited request. Please ensure that you attach a substantiating letter from your physician or treating provider that substantiates the medical condition involved in the adverse determination is serious enough to jeopardize the life or health of the covered person or covered person's ability to regain maximum function (letter must include specifics as to why this request should be expedited).

1. Select a File:


Describe the type of file you are attaching.

Examples: Driver's License, Case History, Policy for ABC Company, Bill from Sparrow Hospital etc.


 Upload

5. Review & Submit

 5. Review & Submit

Review Request

Below you will find the details of the request for an external review you have completed. If you need to make changes, you may use the 'Previous' button or edit links next to each section to make changes.

WARNING: You did not include a substantiating letter with your request. Your request will be accepted, however, it will be reviewed in our NON-EXPEDITED PROCESS if your treating provider does not substantiate that your condition meets criteria for an expedited review.

Contact Information  Edit This Section

Request Filed By: 

Relationship to Patient: 

Name: 

Address:

Contact Information:

Patient Name: 

Patient Address:

Patient Contact Information:

Expedited Review  Edit This Section

Substatiating Physician: 

Substantiating Physician Phone: 

Internal Review Date:

You did not indicate that your request met the requirements for an expedited review.

Health Carrier Details  Edit This Section

Additional Details  Edit This Section

Adverse Determination Date:

Involved Physicians and Medical Facilities
Service Dates

Details of your complaint:

Desired Outcome:

Attachments:

*Authorization
 Submit