Form FIS2326 "Treating Provider Certification for Experimental/Investigational Denials" - Michigan

What Is Form FIS2326?

This is a legal form that was released by the Michigan Department of Insurance and Financial Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FIS2326 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS2326 "Treating Provider Certification for Experimental/Investigational Denials" - Michigan

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FIS 2326 (04/20) Michigan Department of Insurance and Financial Services
TREATING PROVIDER CERTIFICATION FOR EXPERIMENTAL/INVESTIGATIONAL DENIALS
(To be completed by the treating provider)
This form must be completed by the treating provider if your request for an external review involves a denial based on
the health plan’s determination that the service is experimental and/or investigational. Part 1 and Part 2 must both be
completed in order for the Michigan Department of Insurance and Financial Services (DIFS) to accept the external
review request.
I hereby certify that I am the treating provider for
(patient/covered person’s name) and
that I have requested the authorization for, or the patient/covered person has received, a drug, device, procedure, or therapy
denied for coverage due to the health plan’s determination that the service is experimental and/or investigational. I understand
that in order for the patient/covered person to obtain the right to an external review of this denial, I must certify that the
patient/covered person’s medical condition meets certain requirements.
Please provide a description of the recommended or requested health care service or treatment that is the subject of the denial.
(Attach additional sheets as necessary.) **PLEASE INCLUDE RELATED MEDICAL RECORDS WITH THIS FORM.**
In my medical opinion as the patient/covered person’s treating provider, I hereby certify the following:
PART 1 (REQUIRED)
One or more of the following must apply (check all that apply):
☐ Standard health care services or treatments have not been effective in improving the covered person’s condition;
☐ Standard health care services or treatments are not medically appropriate for the covered person; and/or
☐ There is no available standard health care service or treatment covered by the health plan that is more beneficial than the
requested or recommended health care service or treatment.
PART 2 (REQUIRED)
One of the following must apply (check all that apply):
☐ The health care service or treatment I have recommended and which has been denied is, in my opinion, likely to be more
beneficial to the patient/covered person than any available standard health care services or treatments.
☐ Scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the
patient/covered person is likely to be more beneficial to the patient/covered person than any available standard health
care services or treatments. Check only if you are a licensed, board-certified, or board-eligible provider qualified to
practice in the area of medicine appropriate to treat the patient/covered person’s condition.
Treating Provider’s Signature
Print Name of Treating Provider
Date
Treating Provider’s Address:
Treating Provider’s Phone Number:
Fax Number:
The completed form can be emailed to difs-healthappeal@michigan.gov, FAXED to 517-284-8838, or mailed to:
DIFS – Office of Research, Rules, and Appeals, Health Care Appeals Section, P.O. Box 30220, Lansing, MI 48909-7720
FIS 2326 (04/20) Michigan Department of Insurance and Financial Services
TREATING PROVIDER CERTIFICATION FOR EXPERIMENTAL/INVESTIGATIONAL DENIALS
(To be completed by the treating provider)
This form must be completed by the treating provider if your request for an external review involves a denial based on
the health plan’s determination that the service is experimental and/or investigational. Part 1 and Part 2 must both be
completed in order for the Michigan Department of Insurance and Financial Services (DIFS) to accept the external
review request.
I hereby certify that I am the treating provider for
(patient/covered person’s name) and
that I have requested the authorization for, or the patient/covered person has received, a drug, device, procedure, or therapy
denied for coverage due to the health plan’s determination that the service is experimental and/or investigational. I understand
that in order for the patient/covered person to obtain the right to an external review of this denial, I must certify that the
patient/covered person’s medical condition meets certain requirements.
Please provide a description of the recommended or requested health care service or treatment that is the subject of the denial.
(Attach additional sheets as necessary.) **PLEASE INCLUDE RELATED MEDICAL RECORDS WITH THIS FORM.**
In my medical opinion as the patient/covered person’s treating provider, I hereby certify the following:
PART 1 (REQUIRED)
One or more of the following must apply (check all that apply):
☐ Standard health care services or treatments have not been effective in improving the covered person’s condition;
☐ Standard health care services or treatments are not medically appropriate for the covered person; and/or
☐ There is no available standard health care service or treatment covered by the health plan that is more beneficial than the
requested or recommended health care service or treatment.
PART 2 (REQUIRED)
One of the following must apply (check all that apply):
☐ The health care service or treatment I have recommended and which has been denied is, in my opinion, likely to be more
beneficial to the patient/covered person than any available standard health care services or treatments.
☐ Scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the
patient/covered person is likely to be more beneficial to the patient/covered person than any available standard health
care services or treatments. Check only if you are a licensed, board-certified, or board-eligible provider qualified to
practice in the area of medicine appropriate to treat the patient/covered person’s condition.
Treating Provider’s Signature
Print Name of Treating Provider
Date
Treating Provider’s Address:
Treating Provider’s Phone Number:
Fax Number:
The completed form can be emailed to difs-healthappeal@michigan.gov, FAXED to 517-284-8838, or mailed to:
DIFS – Office of Research, Rules, and Appeals, Health Care Appeals Section, P.O. Box 30220, Lansing, MI 48909-7720