Michigan Prior Authorization Law

Overview

Michigan PA 248 (2022) establishes prior authorization timelines: 5 business days for standard requests and 48 hours for urgent requests. Notably, Michigan permits gold-carding for providers with 90%+ approval rates, reducing administrative burden. All denials require clinical rationale.

Key Requirements

1. Insurers must acknowledge PA requests within 24 hours and provide decision timeline.
2. Standard PA decisions within 5 business days; urgent decisions within 48 hours.
3. All PA denials must include specific clinical rationale tied to policy and patient presentation.
4. Gold-carding: providers with 90%+ approval rate may skip PA for designated services.
5. Appeal procedures and external review access must accompany each denial.

Penalties and Enforcement

Michigan DIFS enforces PA timelines and denial requirements. Insurers who miss deadlines face fines. Denials without clinical rationale violate PA 248. Providers can bill at usual and customary rates if insurer misses deadline. Repeat violations trigger license sanctions.

Appeals and Exceptions

Urgent PA requests receive 48-hour expedited response. Denials may be appealed within 10 business days. Independent external review is available if internal appeals fail. Gold-carded providers bypass PA for qualifying services. Certain denial codes may trigger expedited review.

Interaction with Federal Law

Michigan PA timelines align with federal standards. The 48-hour urgent timeline matches federal requirements. Michigan's gold-carding provision exceeds federal law. Providers benefit from gold-card efficiency. NSA rules work alongside PA timelines.

Common Questions