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
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.
- Click on the "Choose File" or "Browse" button below to browse your device for a file.
- Select the kind of document you are attaching using the Select a File Type dropdown
- 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@example.com, 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.
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.