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How CA Health Care Consumers Can Get Help Fighting for a Denied Claim

by John Hansen

60% of Californians Who File an IMR with the DMHC Get Health Care Denials Reversed

The Consumer Help Center at the Department of Managed Health Care (DMHC) has assisted more than 1.7 million Californians resolve complaints and issues with their CA health care plans. Their services are fast, free and confidential. Deputy Director, Mary Watanabe, says that the DMHC is the “best kept secret in California.”

If your California health plan denies, delays or modifies your request for care you can apply for an independent Medical Review (IMR). If an IMR is decided in your favor, the plan must provide the requested service. “Approximately 60% of IMR requests result in the consumer receiving the requested service,” says Mary Watanabe.

There are two steps in the health plan grievance process.

1) File with your health plan

First, file a grievance or complaint with your California health insurance plan. Plans are required by law to resolve enrollee complaints within 30 days. If there is an immediate threat to your health or your request was denied as experimental/investigational, you may seek immediate assistance from the Department of Managed Health Care.

You can file a complaint with your CA health care plan by phone, by mail, or on the plan’s website. If you are not satisfied with your health plan’s decision or if you have not received the plan’s decision within 30 days, you can file a complaint with the DMHC.

2) File for an Independent Medical Review (IMR) with the DMHC

You can complete the IMR/Complaint Form online for fastest processing. The form is available in English and Spanish. When filling in the form, include as much information as possible. You may attach additional notes or documentation. Provide medical records only if CA health care services were provided by an out-of-network provider. The DMHC will obtain medical records from the health plan.

If there is an immediate threat to your health, indicate on the form that this is an urgent or emergency issue that requires an expedited review. If available, include a physician certification of immediate threat to your health.

If you are a CA health care insurance agent and you are assisting a client, have the patient sign and date the form and include Authorized Assistant information, if assistance is needed.

Watanabe said, “A broker can be an authorized assister. Keep in mind that you need the consumer signature and a 2nd signature authorizing you to be the assister. Sometimes I get 20 forms, but can’t process them because I don’t have signatures. You can mail or fax the information.” She also said not to send information by email. Consumers or agents can submit information with the online form, by mail or by fax.

Or, Just File a Complaint with the Department

Mary Watanabe said, “If an issue doesn’t meet the criteria for the Independent Medical Review, there is a complaint process.” A consumer complaint is a general complaint about a health plan, provider, or medical group. Complaints generally include one or more of the following:

  • Delays in getting an appointment, referral, or authorization
  • Claims, billing and co-payment issues
  • Terminations or cancellations of health coverage
  • Access to translation and interpretation services
  • Finding an in-network doctor, hospital or specialist
  • Complaints about a doctor or health plan
  • Doctor or hospital is no longer with your health plan (Continuity of Care)

Click the following link to file a complaint online with the Department of Managed Health Care regarding your CA health care.