A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan
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California
General Information and Internal Plan Review:
California’s Department of Managed Health Care provides a 24-hour-a-day, seven-day-a-week HMO Help Center. The HMO Help Center administers the independent medical review program. Applications for Independent Medical Review (IMR) are submitted directly to the HMO Help Center. If eligible for review, cases are decided by an accredited review organization performing services under a state contract. The Department adopts the IMR decisions, which are binding on the health plan or HMO. The Department resolves problems for commercial as well as Medi-Cal (Medicaid) HMO enrollees.
The California Department of Insurance also receives and process applications for IMR with substantially the same application and review process for decisions made by health insurance companies. The Complaint Resolution and Independent Medical Review Process:
Whom to contact: | California Department of Managed Health Care’s HMO Help Center (or the Department of Insurance, depending on the type of coverage you have). | Who can appeal: | You, your provider (with consent), or your authorized representative | What you can appeal: | An HMO’s or health plan’s decision, including ones regarding experimental or investigational treatment and disputed medical necessity services. | When you can appeal: | A review must be requested within 6 months of when requested care was denied or grievance determination, whichever is later. | What to send: | An application for IMR or the equivalent information with the patient’s authorization to release medical records and information. Call the HMO Help Center for more information or obtain forms at http://www.dmhc.ca.gov/imr/forms/ | What you must pay: | No charge | What will happen: | The California HMO Help Center will: - Determine what the best course of action is for your complaint, including Independent Medical Review.
If you qualify for Independent Medical Review, you will: - Be notified that the case has been accepted.
- Have an opportunity to submit supporting information to the review. (The health plan will submit all medical records in its possession to the assigned review organization - you may but are not required to provide additional medical records.)
- Receive a written analysis and determination, adopted by the Department.
| When you will get a decision: | Usually within 30 days | In urgent situations: | Call the Department’s HMO Help Center for emergency or urgent situations. |
How to Get More Information: Information updated as of 9-15-2004 |
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