Department of Managed Health Care (DMHC)

If the IMR is decided in your favor, your health plan must authorize and provide the requested service or treatment.

Generally, a doctor, hospital, or other provider in your health plan's network can bill you for your cost-share under your contract with your health plan, such as a deductible, co-pay, or co-insurance. If you get a bill for another cost, call the billing office that sent you the bill and ask them to explain the bill to you. If you disagree and believe you are being wrongfully billed, file a complaint with your plan. If your plan does not resolve the issue within 30 days or you are not satisfied with your plan's decision, contact the DMHC Help Center at www.DMHC.ca.gov or at 1-888-466-2219.

The Consumer Complaint process assists consumers in resolving issues with their health plans. These issues can consist of billing problems, cancellation of coverage, claim and copay disputes, delays in getting an appointment, referral or authorization for care, access to translation services, finding an in-network doctor, hospital, or specialist, complaints about a doctor or plan and continuity of care. 

If your health plan denies, changes or delays your request for medical services, denies payment for emergency treatment or refuses to cover experimental or investigational treatment for a serious medical condition, you can apply for an Independent Medical Review (IMR).

During an IMR, independent doctors and medical providers, who do not work for your health plan, will examine your case to see if your health plan appropriately denied services or if you should receive the requested service or treatment. These doctors may discover that your health plan was wrong to deny you care. If the IMR is decided in your favor, your plan must authorize and provide the service(s) or treatment(s) you requested. IMR’s are free to enrollees.