Are you a consumer with a complaint about your health plan or your treatment? We can help. Fill out our Complaint Form or call our Help Center at 888-466-2219, and we will determine whether it qualifies for an Independent Medical Review (IMR) or a Consumer Complaint. Once we make this determination, we’ll help you proceed with the steps you need to submit your complaint. In most cases, before filing complaints with us, you need to file a complaint with your health plan. If this is the case, we’ll help you obtain the paperwork you’ve already submitted so you don’t have to start from scratch.
What is the difference between an IMR and a Consumer Complaint?
Many people want to know the difference between a Consumer Complaint and an IMR. In general, a consumer complaint is a general complaint about your health plan, provider or medical group. Common issues include not getting a referral or treatment you want, waiting too long for an appointment, getting discharged from the hospital, poor care, or rude treatment. You have the right to file a complaint against these and other issues.
An Independent Medical Review is an independent review of a specific complaint about treatment, such as when your plan won’t cover a drug because it says it’s experimental. This is done by doctors who aren’t part of your health plan, and under law an IMR must be resolved within 30 days.
Remember: we will help you determine what path to take. Contact us today at 888-466-2219.
Do I Qualify?
You qualify for an IMR when:
- Your plan doesn’t give you a decision within 30 days.
- Your problem is an immediate and serious threat to your health and your plan doesn’t respond within 3 days.
- Your plan covers prescription drugs and it says that the drug you asked for is not medically necessary or is experimental or investigational.
Our staff will help you determine whether your issue qualifies as an IMR or Consumer Complaint.
Many plan members can qualify for an IMR, including those in a Medical-managed health plan. If you are in Medi-cal, you can also ask for a Medi-Cal State Hearing, which is a review of your problem by the state, by calling 1-800-952-5253. However, if you have had a Medi-Cal State Hearing you cannot get an Independent Medical Review from our Help Center. If you get an Independent Medical Review from the Help Center and you are not satisfied with the result, you can still get a Medi-Cal State Hearing.
The following groups don’t qualify for an IMR:
- Medicare. If you are in Medicare Advantage, you must file an appeal with the health plan. Or you can call the Health Services Advisory Group (HSAG) at 1-818-409-9229. HSAG is an organization that has a contract with Medicare to help members with appeals.
- Medi-Cal fee-for-service members (Medi-Cal members who are not in managed care) cannot get an IMR.
- Members of self-insured or self-funded group health plans. These are health plans that are usually through a large employer. The employer pays doctors, hospitals, and other providers directly for employees' health care, instead of paying a premium to an HMO or other insurance company to provide the health care.
For many years, most Californians have the right to appeal through the state’s Independent Medical Review Laws. Under the Affordable Care Act, the right to appeal has been extended to those who are self-employed. This protection starts with plan years that began on or after July 1, 2011.
Learn more about Your Right to Appeal
Steps for Filing
1. Start your health plan's complaint process
You must go through your health plan’s complaint process, unless your plan denied treatment because it was experimental or investigational. In this case, you can immediately file an IMR.
How to File a Complaint with Your Health Plan
You can file a complaint with the DMHC when your plan is one of the 120 plans regulated by us. To figure out if you qualify, View All DMHC Regulated Plans.
To print out a form:
- Select the language you want.
- Complete and sign the form.
- Fax or mail the form and copies of any supporting documents to:
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814-2725
You must have a computer program called Adobe Reader to print the forms below. You can download Adobe Reader for free to your computer. Click on Adobe for directions.
3. Attach documentation
Include copies of letters or other documents about the treatment or service that your health plan denied. Remember to send copies of documents, not originals, since the Help Center cannot return any documents.
4. Call the Help Center at 1-888-466-2219 or (TDD) 1-877-688-9891 if you have questions about filling out your application
5. Mail or fax your form and any attachments to:
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
6. Await acknowledgement
The Help Center will review your application and send you an acknowledgement of receipt letter within 5 days. The IMR/Complaint decision is then made within 30 days, or within 3 to 7 days if your problem is urgent.
7. Receive Care
If the IMR is decided in your favor, your health plan must provide the service or treatment. The Help Center will make sure that you receive the service or treatment.
- You must apply for an IMR/Complaint with the DMHC within 6 months after your health plan sends you a written decision about your issue.
- If your health problem is urgent, ask for an expedited IMR, in order to get a response within 3 days.
- An IMR can take longer if we don’t receive all of the medical records that we need from you. If you are seeing a doctor who is not in your health plan's network, it’s important that you send us your medical records from that doctor. Your health plan is required to get copies of your medical records from doctors who are in the network.
IMR Frequently Asked Questions
What is an Independent Medical Review (IMR)?
An IMR is a review of your case by doctors who are not part of your health plan. If the IMR is decided in your favor, your plan must give you the service or treatment you requested. You pay no costs for an IMR.
If your health plan denies your request for medical services or treatment, you can file a complaint (grievance) with your plan. If you disagree with your plan's decision, you can file an IMR/Complaint with the DMHC. The DMHC staff will determine whether your issue qualifies as an IMR or Consumer Complaint.
What are my chances of getting a service that my health plan has denied?
In more than 50% of qualified IMR cases, the health plan’s denial of service was overturned and the enrollee got the requested medical treatment. Once the case has been decided, the health plan must authorize the services in five business days. The IMR is free, easy, and fast - in most cases, the IMR is decided within 30 days of receiving all required documentation. If you need more local, one-on-one assistance in filling out the IMR form, please contact the DMHC or the DMHC’s Consumer Assistance Program, Health Consumer Alliance, at 1-888-804-3536.
What if my plan says the service I want is not covered in my benefit package?
Complete and submit the IMR/Complaint Form online or by mail anyway. The DMHC will review your IMR/Complaint Form application to decide if the service you want is covered and if your issue qualifies for a consumer complaint. If the service is not covered, we will tell you that you do not qualify for an IMR.
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.