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 ask the Help Center for 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.
You Can Apply for an IMR if Your Health Plan:
- Denies, changes, or delays a service or treatment because the plan determines it is not medically necessary.
- Will not cover an experimental or investigational treatment for a serious medical condition.
- Will not pay for emergency or urgent medical services that you have already received.
Before You Apply
In most cases, you must complete your health plan's complaint process before you apply for an IMR. Your plan must give you a decision within 30 days or within 3 days if your problem is an immediate and serious threat to your health.
If your plan denied your treatment because it was experimental/ investigational, you do not have to take part in your plan's complaint process before you apply for an IMR.
You must apply for an IMR within 6 months after your health plan sends you a written decision about your complaint.
How to Apply
- Fill out the 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 to:
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
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.
Questions and Answers About IMR
IMR Application Form
Search IMR Decisions