Independent Medical Review
An independent medical review (IMR) is when an outside reviewer who is not related to your health plan reviews your case. If you want an IMR, you must first file an appeal with PHC California. If you do not hear from your health plan within 30 calendar days, or if you are unhappy with your health plan’s decision, then you may then request an IMR. You must ask for an IMR within six (6) months from the date on the notice telling you of the appeal decision.
You may be able to get an IMR right away without filing an appeal first. This is in cases where your health is in immediate danger.
Here is how to ask for an IMR. The term “grievance” is for “complaints” and “appeals.”
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800-263-0067 (TTY 711) and use your health plan’s grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department’s internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online. (By clicking on the link above, you will be taken to a website operated by DMHC and not PHC California.)
For more information about the appeals process, see Section 5, Reporting and Solving Problems, in the Member Handbook (Combined Evidence of Coverage (EOC) and Disclosure Form) (effective 2022).
DHCS 030716 PHC FR Form 1.0