CurrentHealth Alliance Plan (HAP)Policy N/A

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

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

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

On This Page

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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.

OpenPayer

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

Form submission requirements

Diagnosis and controlled-substance coding

Submission, review timeframes, and follow-up

Key statutory definitions