Appealing Denied Health Care Services Through the Calif. Dept. Of Managed Health Care

An analysis of the results of Independent Medical Reviews (IMR) by the California Department of Managed Health Care shows that if a patient appeals a denial, about half the time, they succeed in getting that decision overturned or withdrawn.

The California Department of Managed Health Care is one of two agencies regulating insurance companies. It focuses on Health Maintenance Organizations (HMOs). Here's how it describes the IMR process:

IMRs are sought when someone is denied a health care service (or reimbursement for a health care service) based on one of these reasons:

• The requested service is not medically necessary (this is the bulk of them)
• The requested service is experimental or investigational
• The plan denies a claim for emergency or urgent health care services because the enrollee wasn’t experiencing an urgent/emergency condition

“The Affordable Care Act provides millions of Americans who were previously denied health coverage the ability to purchase a plan," says Marta Green, Deputy Director of Communications with the California Department of Managed Health Care. "The Independent Medical Review process guarantees that health plan enrollees get the medically necessary care they need.”

Take a look at the success rates of patient appeals through the California Department of Managed Health Care from 2006 through 2012. The insurance companies highlighted in the breakdown are ones that have more than 400,000 people enrolled.

Click here to see an interactive graphic on patient success rate

How to apply: Complaint/Independent Medical Review (IMR) Application Form

Attach copies of letters or other documents about the treatment or service that your health plan denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.

If you have questions about filling out your application form, call the Help Center at 1-888-466-2219 or (TDD) 1-877-688-9891. There is no charge for this call.

Mail or fax your form and any attachments

What Happens Next: The Help Center will review your application and send you a letter within 5 days. This letter will tell you if you qualify for an IMR. The IMR decision is then made within 30 days, or within 3 to 7 days if your problem is urgent.

If the IMR is decided in the patient's favor, the health plan must provide the service or treatment. The Help Center will make sure that the patient receives the service or treatment.

Source: California Department of Managed Health Care