Independent Medical Review (IMR)
You may file an Independent Medical Review (IMR) from the Department of Managed Health Care (DMHC). You have up to six months from the date of denial to file an IMR. You will get info on how to file an IMR with your denial letter. You may reach DMHC toll-free at 1-888-HMO-2219 or 1-888-466-2219.
You may still have a State Fair Hearing if you request an IMR. However, you will not be able to use the IMR process if you have asked for a State Fair Hearing.
There are no fees for an IMR. You have the right to provide info to support your request. A decision not to take part in the IMR process may cause you to lose certain legal rights. This could hinder your pursuit of legal action against the plan.
When to File an IMR
You may file an IMR if you meet the below criteria:
- Your doctor says you need a health care service because it is medically necessary and it is denied; or
- You received urgent or emergency services determined to be necessary and they were denied; or
- You have seen a network doctor for the diagnosis or treatment of the medical condition, even if the health care services were not recommended.
- The disputed health care service is denied, changed or delayed by California Health & Wellness based in whole or in part on a decision that the health care service is not medically necessary, and
- You have filed a grievance with California Health & Wellness and the health care service is still denied, changed, delayed or the grievance remains unresolved after 30 days
You must first go through the grievance process before applying for an IMR. In special cases, the DMHC may not require you to follow the process before filing an IMR. The dispute will be sent to a medical specialist if it is eligible. The specialist will decide if the care is medically necessary. You will receive a copy of the IMR decision from DMHC. If it is decided that the service is medically necessary, the health plan will provide the service.
For non-urgent cases, the IMR decision must be made within 30 days. The 30-day period starts when your application and all documents are received by DMHC.
If your grievance needs a fast review, you may bring it to DMHC’s attention right away. You will not need to participate in the grievance process.
For urgent cases the IMR decision must be made within three calendar days.
Examples of urgent cases include:
- Severe pain
- Potential loss of life, limb or major bodily function
- Immediate and serious deterioration of your health
IMRs for Experimental and Investigational Therapies (IMR-EIT)
You can file an IMR-EIT through the DMHC when a medical service, drug or equipment is denied. A denial can happen if it is experimental in nature. You will be notified in writing that you may request an IMR-EIT within five days of the decision to deny coverage. You have up to six months from the date of denial to file an IMR-EIT. You may give info to the IMR-EIT panel. You will get a written decision within 30 days from when your request was received. If your doctor thinks that the proposed therapy will be less effective if delayed, the decision will be made within seven days of the request for an expedited review. In urgent cases the IMR-EIT panel will give you a decision within three business days from the time your info is received.
You may file an IMR-EIT if:
- You have a very serious condition that is "life threatening".
- Your doctor must certify that.
- The standard treatments were not or will not be effective, or
- The standard treatments were not medically appropriate, or
- The proposed treatment will be the most effective
- Your doctor certifies in writing that:
- A drug, device, procedure or other therapy is likely to work better than the standard treatment
- Based on two medical and scientific documents, the recommended treatment is likely to work better than the standard treatment
- You have been denied a drug, equipment, procedure or other therapy recommended or requested by your doctor.
- The treatment would normally be covered as a benefit, but California Health & Wellness has determined that it is experimental in nature.
To find out more please call member services at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number).
You do not need to participate in the grievance process before asking for an IMR of a decision to deny coverage on the basis that the treatment is experimental in nature.