CurrentHealth Alliance Plan (HAP)Policy N/A

Michigan standard prior authorization form for prescription drugs (FIS 2288)

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Governs use of the Michigan Department of Insurance and Financial Services standard prior authorization form (FIS 2288) for prescription drug prior authorization requests submitted by prescribers to health plans in Michigan.

Policy Summary

PayerHealth Alliance Plan (HAP)

PolicyMichigan standard prior authorization form for prescription drugs (FIS 2288)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionUse FIS 2288 to initiate a prescription drug prior authorization request and indicate Expedited Review Request when a 15-day standard review may seriously jeopardize patient life or health.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

72h / 15dinsurer response timeframe (expedited / standard)

5d / 21dprescriber time to submit additional info (expedited / standard)

FIS 2288standard form

A–Iform sections

Form submission requirements

Form submission criteria

Form sections and required information to support prior authorization review:

Request Type: indicate whether this is an Initial Authorization Request, a Renewal Request, or a Dispense as Written (DAW) request.

Patient Demographics: provide patient name, date of birth, health plan ID, sex, and whether the patient is hospitalized.

Prescriber Information: provide prescriber name, NPI, specialty, contact name/phone/fax, health plan provider ID if accessible; include DEA number when the request is for a controlled substance.

(DEA required only for controlled substance requests)

Pharmacy Information (optional): include pharmacy name and pharmacy telephone if available.

Optional field on the form

Requested Prescription Drug Information: provide drug name, strength, dosing schedule, duration, the specific diagnosis with ICD-10 code, place of infusion/injection if applicable, facility/provider NPI, and indicate whether the patient has already started the medication (and date if so).

Diagnosis with ICD# is requested on the form

Rationale and Clinical Support: include a history of present illness, past medical history, current medications, failed or contraindicated therapies, and any pertinent labs or measures of response; attaching chart notes is recommended to support the request.

Insufficient clinical information may result in extended review or adverse determination

Failed / Contraindicated Therapies: document prior therapies with drug name, strength, dosing, duration, and adverse events or specific failures for each.

Health Plan Use / Plan Decision Fields: for plan use only — record request date, line of business, approval/denial, effective date, reason for denial, additional comments, and obtain signatures and attestations regarding truthfulness of information provided.

Form contains attestation; false information may be insurance fraud

Diagnosis and controlled-substance coding

Diagnosis (ICD-10)ICD-10

ICD-10 (diagnosis required)

Diagnosis with ICD# is requested on the form

Controlled substance DEA requirement — DEA number required on form for controlled substance requests

RequirementDEA number is required on the form for controlled substance requests (field D: ‘DEA (required for controlled substance requests only)’) .

Location on formPrescriber Information section (Section D) includes the DEA field.

Applies toOnly requests involving controlled substances when prescriber is submitting prior authorization via FIS 2288.

Submission, review timeframes, and follow-up

Note

Submission and expedited designation — use FIS 2288

Use the Michigan Prior Authorization Request Form (FIS 2288) to initiate prior authorization requests. If the prescriber believes that waiting the standard review period may seriously jeopardize the patient’s life, health, or ability to regain maximum function, the prescriber must check the Expedited Review Request box and certify that Expedited Review is required.

Form: Michigan Prior Authorization Request Form for Prescription Drugs (FIS 2288)
To designate Expedited Review the prescriber must certify risk to life/health or ability to regain maximum function

Prior Authorization

Insurer response timeframes and deemed grant

Insurer response timeframes: For expedited prior authorization requests, the insurer must grant, deny, or request additional information within 72 hours of the date and time of submission. For standard prior authorization requests, the insurer must grant, deny, or request additional information within 15 days of the date and time of submission. Deemed grant (failure to respond): If the insurer fails to grant, deny, or request additional information within the applicable timeframe (72 hours for expedited; 15 days for standard), the prior authorization is considered granted. If the insurer requests additional information and the prescriber submits that information, the insurer must grant, deny, or request further information within 72 hours of receipt for expedited requests or within 15 days of receipt for standard requests; failure to do so after receipt results in a deemed grant.

Expedited: insurer action required within 72 hours of submission
Standard: insurer action required within 15 days of submission
If additional information is requested, the same 72-hour (expedited) or 15-day (standard) deadline applies starting from the insurer’s receipt of the additional information

Documentation Required

Additional information requirements and voiding rules

If the insurer requests additional information, the prescriber must submit the requested information promptly. Timelines for voiding: a prior authorization request is considered void if the prescriber fails to submit the requested additional information within 5 days after the original submission for a properly completed expedited request, or within 21 days after the original submission for a properly completed standard request. Prescribers should ensure contact information and submission completeness to avoid voiding.

Prescriber must provide additional information when requested by insurer
Expedited requests: prescriber has 5 days from original submission to supply requested additional information or the request becomes void
Standard requests: prescriber has 21 days from original submission to supply requested additional information or the request becomes void

Key statutory definitions

Prescriber — definition per MCL 333.17708

Statutory reference'Prescriber' means the term as defined in section 17708 of the Public Health Code, 1978 PA 368, MCL 333.17708.

Context of useDefinition is used to identify who may complete and certify the prior authorization form (FIS 2288).

Form implicationPrescribers must provide their name, NPI, specialty, contact info, and applicable DEA on the form as identified in Section D.

Prescription drug — definition per MCL 333.17708

Statutory reference'Prescription drug' means the term as defined in section 17708 of the Public Health Code, 1978 PA 368, MCL 333.17708.

Form contextThe form is provided for prior authorization requests for prescription drugs and uses this statutory definition to scope applicable medications.

Interaction with timelinesPrior authorization processing timeframes and expedited review criteria apply to requests for 'prescription drugs' as defined by MCL 333.17708.

Policy Summary

PayerHealth Alliance Plan (HAP)

PolicyMichigan standard prior authorization form for prescription drugs (FIS 2288)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionUse FIS 2288 to initiate a prescription drug prior authorization request and indicate Expedited Review Request when a 15-day standard review may seriously jeopardize patient life or health.

SourceLink

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Michigan standard prior authorization form for prescription drugs (FIS 2288)

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Sign up for all Health Alliance Plan (HAP) policy alerts

Know when Health Alliance Plan (HAP) releases new policies or updates existing guidance.

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Form submission requirements

Form submission criteria

Form sections and required information to support prior authorization review:

Request Type: indicate whether this is an Initial Authorization Request, a Renewal Request, or a Dispense as Written (DAW) request.

Patient Demographics: provide patient name, date of birth, health plan ID, sex, and whether the patient is hospitalized.

Prescriber Information: provide prescriber name, NPI, specialty, contact name/phone/fax, health plan provider ID if accessible; include DEA number when the request is for a controlled substance.

(DEA required only for controlled substance requests)

Pharmacy Information (optional): include pharmacy name and pharmacy telephone if available.

Optional field on the form

Diagnosis with ICD# is requested on the form

Insufficient clinical information may result in extended review or adverse determination

Failed / Contraindicated Therapies: document prior therapies with drug name, strength, dosing, duration, and adverse events or specific failures for each.

Form contains attestation; false information may be insurance fraud

Diagnosis and controlled-substance coding

Diagnosis (ICD-10)ICD-10

ICD-10 (diagnosis required)

Diagnosis with ICD# is requested on the form

Controlled substance DEA requirement — DEA number required on form for controlled substance requests

RequirementDEA number is required on the form for controlled substance requests (field D: ‘DEA (required for controlled substance requests only)’) .

Location on formPrescriber Information section (Section D) includes the DEA field.

Applies toOnly requests involving controlled substances when prescriber is submitting prior authorization via FIS 2288.

Submission, review timeframes, and follow-up

Note

Submission and expedited designation — use FIS 2288

Form: Michigan Prior Authorization Request Form for Prescription Drugs (FIS 2288)
To designate Expedited Review the prescriber must certify risk to life/health or ability to regain maximum function

Prior Authorization

Insurer response timeframes and deemed grant

Expedited: insurer action required within 72 hours of submission
Standard: insurer action required within 15 days of submission
If additional information is requested, the same 72-hour (expedited) or 15-day (standard) deadline applies starting from the insurer’s receipt of the additional information

Documentation Required

Additional information requirements and voiding rules

Prescriber must provide additional information when requested by insurer
Expedited requests: prescriber has 5 days from original submission to supply requested additional information or the request becomes void
Standard requests: prescriber has 21 days from original submission to supply requested additional information or the request becomes void

Key statutory definitions

Prescriber — definition per MCL 333.17708

Statutory reference'Prescriber' means the term as defined in section 17708 of the Public Health Code, 1978 PA 368, MCL 333.17708.

Context of useDefinition is used to identify who may complete and certify the prior authorization form (FIS 2288).

Form implicationPrescribers must provide their name, NPI, specialty, contact info, and applicable DEA on the form as identified in Section D.

Prescription drug — definition per MCL 333.17708

Statutory reference'Prescription drug' means the term as defined in section 17708 of the Public Health Code, 1978 PA 368, MCL 333.17708.

Form contextThe form is provided for prior authorization requests for prescription drugs and uses this statutory definition to scope applicable medications.

Interaction with timelinesPrior authorization processing timeframes and expedited review criteria apply to requests for 'prescription drugs' as defined by MCL 333.17708.