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Michigan FIS 2356: Auto Insurance UR Provider Appeal

Michigan health care providers use FIS 2356 to appeal an auto insurer's or the MCCA's utilization review determination to DIFS when the insurer found treatment not medically necessary, the cost inappropriate, or both. The four-page form identifies the provider, injured person, insurer and each disputed date of service and procedure code, and lists the documents required for each type of appeal.

Who completes it

The health care provider named on the insurer's determination (physician, hospital, clinic or other provider) completes the applicable sections, and an authorized person signs Section X. The injured person has no active role in the appeal.

Submitting and payment

How to submit it
Email the form and all supporting documents to DIFS's utilization review appeals address within 90 days of the insurer's determination or bill denial; faxes are no longer accepted. Mail is allowed but slower.
Who pays
The appeal concerns the insurer's payment for the services; separately, an insurer that asks for records beyond those normally sent with a bill must reimburse a reasonable and customary fee plus copying and mailing costs.

Good to know

  • List procedure codes, not diagnosis codes, and avoid date ranges unless services were given on every date; the provider name must match the insurer's determination.
  • DIFS does not accept additional documentation after filing, so send the narrative, every page of each determination, the billing form and records at the start.
  • Cost disputes for accidents on or after June 11, 2019 also need the charge description master in effect on January 1, 2019, or the average charge, and form FIS 2376.
  • Billing and coding errors, coverage questions, pending litigation and bills with no written determination are outside utilization review and cannot be appealed this way.

Get the official form

Download the current version from the source each time; forms change without notice.

Provider Appeal Request (Auto Insurance Utilization Review)

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What is the deadline for a Michigan auto insurance utilization review appeal?

The appeal must reach DIFS within 90 days of the date of the insurer's disputed determination or bill denial. Late appeals cannot be reviewed by DIFS but may still be resolved directly with the insurer. If the insurer sent a request for explanation, the provider may appeal once the 30-day response period has passed.

Which sections of FIS 2356 must be completed?

A medical necessity appeal needs Sections I to V, VII and X. A cost appeal needs Sections I to VI, VIII or IX depending on the accident date, and X. An appeal on both grounds needs Sections I to VII, VIII or IX, and X.

What happens after the appeal is filed?

The email address in the provider section should hear from DIFS within 21 days. DIFS sends a Notice of Appeal within 14 days of accepting it, the insurer may reply on FIS 2361, and DIFS then emails a final order to both parties, which can be taken to circuit court for judicial review.