Submit an IMR/Complaint Form

• If your health problem is urgent an IMR is usually decided within 7 days after the request qualifies for an IMR and the required documentation has been received by the DMHC’s Independent Medical Review Organization. This is called an expedited IMR. A health problem is urgent if it is a serious and immediate threat to your health. Your doctor must send us written documentation that your health problem is urgent.
• If your health problem is not urgent, an IMR is usually decided within 30 days after we receive the supporting documentation from you, the doctor and the health plan.

Visit https://www.dmhc.ca.gov/FileaComplaint/FrequentlyAskedQuestions.aspx for more information.

• Your health plan may cancel your coverage if you or your employer did not pay your premiums. If this happens, call your plan right away and try to arrange payment.
• A health plan can also cancel coverage if the member used fraud and deception to get services or violated the contract in other ways.
• Your coverage may also end because your employer stops offering health coverage to employees.
• If you think your coverage was cancelled because of your health condition or because you need medical care, contact the Help Center.

It means that your plan believes that the service you or your doctor requested is not appropriate for your medical condition, or the plan wants you to try a different treatment. Sometimes doctors and health plans do not agree on what is medically necessary.

The Consumer Complaint process assists consumers in resolving issues with their health plans, including the following types of complaints:

• Improper denial or delay in settlement of a claim.
• Health claims that have been denied by the health plan because the service or treatment is not covered under the contract.
• Legal interpretations of policy language, provisions, and terms.
• Bad faith allegations and other demands for extra payments under the health insurance contract.
• Alleged illegal cancellation or termination of a policy.
• Alleged misrepresentation by an agent, broker, or solicitor.
• Alleged theft of premiums paid to an agent, broker, or solicitor.
• Issues with providers, medical groups and pharmacies.

An IMR is a review of your case by independent doctors who are not part of your health plan. You have a good chance of receiving the service(s) or treatment(s) you need by requesting an IMR. Approximately 60% of enrollee’s that submit IMR requests to the DMHC receive the service(s) or treatment(s) they requested. If the IMR is decided in your favor, your plan must authorize the service(s) or treatment(s) you requested. IMR’s are free to enrollees.

If your health plan denies your request for medical services or treatment, you can file a complaint (grievance/appeal) with your plan. If you disagree with your plan's decision, or it has been at least 30 days since you filed a complaint with your health plan you can request an IMR with the DMHC. The DMHC staff will determine whether your issue qualifies for an IMR.

A request will qualify for an IMR if your Health Plan:

• Denies, modifies, or delays a service or treatment because the health plan determines it is not medically necessary.
• Will not cover an experimental or investigational treatment.
• Will not pay for emergency or urgent medical services that you have already received.

• Medicare enrollees.
• Medi-Cal fee-for-service members (Medi-Cal members who are not in a managed care plan).
• Members of self-insured, self-funded, and ERISA plans.
• An enrollee that is disputing a worker’s compensation claim.