Updated Utilization Review Forms ______________________________

STATE OF MICHIGAN DEPARTMENT OF INSURANCE AND FINANCIAL SERVICES Bulletin 2026-01-INS In the matter of: Updated Utilization Review Forms ______________________________/ Issued and entered this 5th day of January 2026 by Anita G. Fox Director This bulletin advises interested parties that the Department of Insurance and Financial Services (“DIFS”) has developed updated versions of its Utilization Review forms (“UR Forms”). To facilitate appeals of determinations under Section 3157a of the Insurance Code, MCL 500.3157a, and Utilization Review Rule 65, Mich Admin Code, R 500.65, DIFS created several UR Forms, including: 1) Application for Unconditional Certification of Auto Insurance Utilization Review Program (FIS 2362); 2) Auto Insurance Utilization Review Provider Appeal Request (FIS 2356); 3) Auto Insurance Utilization Review Insurer Reply to Provider Appeal (FIS 2361); 4) Auto Insurance Utilization Review Insurer Annual Report (FIS 2358); and 5) Auto Insurance Utilization Review Provider Attestation (FIS 2376). Primarily for the sake of clarity, DIFS has amended its UR Forms, which may be accessed online at https://www.michigan.gov/difs/utilization-review under the heading “Utilization Review Forms.” As of February 15, 2026, DIFS will no longer accept outdated UR Forms. DIFS therefore expects providers and insurers to update their processes to exclusively use, and include in their communications as necessary, the revised UR Forms identified in this bulletin and to discontinue the use of, and reference to, any outdated UR Forms. Any questions regarding this bulletin should be directed to: Department of Insurance and Financial Services Office of Appeals and Market Regulation 530 West Allegan Street, 7th Floor Lansing, Michigan 48933 Toll Free: (877) 999-6442 /s/ _________________________________________ Anita G. Fox Director