Submit an IMR/Complaint Form

Department of Managed Health Care

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Description

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). You can also file a Consumer Complaint when you have other issues with your health plan. These issues can consist of billing problems, cancellation of coverage, claim and copay disputes, delays in getting an appointment, referral or authorization, access to translation services, finding an in-network doctor, hospital, or specialist, complaints about a doctor or plan and continuity of care. Fill out and submit an IMR/Complaint Form online or call the DMHC Help Center at 1-888-466-2219 for assistance.

Phone: 888-466-2219

Frequently Asked Questions

Can another person help me submit an Independent Medical Review or Consumer Complaint?
Yes. You must complete and sign the DMHC Authorized Assistant Form. The DMHC cannot speak to anyone about your Independent Medical Review or Consumer Complaint unless we have your authorization to do so. Completion and submission of the DMHC Authorized Assistant Form tells the DMHC that it has your permission to speak with the person you have designated as your authorized assistant or representative.
Can I get an IMR if my plan will not pay for the medicine I think I need?

If your plan covers prescription drugs and it says that the drug you asked for is not medically necessary or is experimental or investigational, you may qualify for an IMR.
How long does an IMR take?
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. This is called an expedited IMR. A health problem is urgent if it is a serious and immediate threat to your health. 

If your health problem is not urgent, an IMR is usually decided within 30 days after all required documentation is received.
What happens if my problem does not qualify for an IMR?

Fill out and submit an Independent Medical Review/Complaint Form online or call the DMHC Help Center at 1-888-466-2219 for assistance. Once your Independent Medical Review/Complaint Form has been received, the DMHC Help Center will determine whether your complaint qualifies for an Independent Medical Review (IMR) or if it will be reviewed as a Consumer Complaint. The DMHC Help Center will contact you to let you know if your issue falls under an IMR or Consumer Complaint.

What happens if the IMR is decided in my favor?
If the IMR is decided in your favor, your health plan must authorize and provide the service or treatment.
What happens if the IMR is decided in my favor?
If the IMR is decided in your favor, your health plan must authorize and provide the requested service or treatment.
What if I get a bill for care that I received?

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.

 
What if I need assistance in filing a grievance with my health plan?

The Department of Managed Health Care contracts with the Health Consumer Alliance, a group of local, community-based organizations that will give you free help with filing a grievance with your health plan. If you need more local, one-on-one assistance, please contact the Health Consumer Alliance’s Consumer Assistance Program at 1-888-804-3536.
What is a Consumer Complaint?
 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.
What is a Consumer Complaint?
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. 
What is an Independent Medical Review (IMR)?

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.
Who can apply for an IMR with the DMHC?
Californians enrolled in a DMHC-regulated health plan are eligible to file a complaint or IMR with the DMHC. Most people who live in California are enrolled in a health plan regulated by the DMHC. Because of this, the DMHC Help Center is a good place to start if you have a problem with your health plan. If you are in a health plan not regulated by the DMHC, the DMHC Help Center will refer you to the right regulator.

Members enrolled in health plans under the following coverage are not eligible to file an IMR with the DMHC. The DMHC Help Center does not have jurisdiction over:

Will my medical condition and treatment stay private?
Yes. Your name, medical records, and all other personal medical information are kept private and confidential under California law. IMR decisions are public, but all personal information is removed including the names and all identifying information of patients, doctors, or facilities.

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