Are you an enrollee with a complaint about your health plan? Has a service/treatment you or your doctor requested been denied, modified or delayed? The Help Center can help. Fill out and submit an Independent Medical Review Application/Complaint Form to the DMHC or call our Help Center at 1-888-466-2219 for assistance. Once your Independent Medical Review Application/Complaint Form has been received, the Help Center will determine whether your complaint qualifies for an Independent Medical Review (IMR) or is reviewed as a Consumer Complaint. Urgent issues are decided quickly, typically within 7 days after IMR qualification and the required documentation has been received. Non-urgent IMR’s and Consumer Complaints are typically decided within 30 days.
What is the difference between an IMR and a Consumer Complaint?
An Independent Medical Review (IMR) is an objective review of your request by doctors outside your health plan. You can request an IMR if your health plan denies, modifies, or delays a health care service or treatment. You have a good chance of receiving the service or treatment you requested by asking for an IMR.
A Consumer Complaint is a general complaint about your health plan, provider, or medical group. Common Consumer Complaint issues include balance billing, billing for services that your health plan states is not a covered benefit, if you have a dispute on the amount paid on a claim, a copay dispute, cancellation of your coverage or if you have a complaint about the provider’s attitude.
You must apply for an IMR or submit a Consumer Complaint to the DMHC within six months after your health plan sends you a written decision about your issue.
How to File a Complaint
- Complete and submit the Independent Medical Review Application/Complaint Form.
- If you have them, attach or send copies of letters or other documents about the service or treatment 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 Independent Medical Review Application/Complaint Form call the Help Center toll free at 1-888-466-2219 or (TDD) 1-877-688-9891.
- You may submit the Independent Medical Review Application/Complaint Form online, by mail or fax:
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 an acknowledgement of receipt letter within 5 days. Urgent IMR decisions are typically determined within 7 days after the case has qualified for an IMR and the required documentation has been received by the DMHC’s Independent Medical Review organization. Non-urgent IMR’s and Consumer Complaint decisions are typically decided within 30 days.
Common Consumer Q&A
Search IMR Decisions
Questions and Answers about Legal Actions
What types of issues does the Help Center review?
Common issues reviewed by the Help Center include:
- You have to wait too long for a referral, authorization, test, or appointment.
- You can’t get the medicine or treatment you need.
- You believe you are being sent home from the hospital too soon.
- Your health care coverage has been terminated/cancelled.
- You have a problem with a bill, claim, or co-pay.
- You received a bill for emergency or urgent care.
- You cannot get services in your language.
- Your doctor or hospital is no longer with your health plan.
Does the Help Center act as my attorney?
No. The Help Center does not give legal advice or act as your attorney.
How will my IMR or Consumer Complaint be reviewed?
After your Independent Medical Review Application/Complaint Form has been received, the Help Center will:
If the IMR or Consumer Complaint is not decided in your favor, you cannot appeal the decision. However, you may still be able to take legal action and may want to speak with a private attorney.
- Open a case, review the submitted documentation, and send the case documentation to your health plan for a written response.
- The Help Center will review your plan's response to determine if the case will be reviewed as an IMR or Consumer Complaint.
- The case is then forwarded to the appropriate unit for further review. This may include review of your complaint by clinical or legal staff.
- If the case qualifies for an IMR the case documentation is sent to the Help Center’s Independent Medical Review organization where independent doctors review your request and provide the decision to the Help Center.
- The Help Center will send you and your health plan a letter that explains our decision.
- If the IMR or Consumer Complaint is decided in your favor, we will require your health plan to authorize the service, or resolve the complaint matter.