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Submit an IMR/Complaint Form

Department of Managed Health Care (DMHC)

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/Complaint Form or call our Help Center at 1-888-466-2219 for assistance. Once your Independent Medical Review/Complaint Form has been received, the Help Center will determine whether your complaint qualifies for an Independent Medical Review (IMR) or if it will be reviewed as a Consumer Complaint. You must submit your Independent Medical Review/Complaint Form to the DMHC within six months after your health plan sends you a written decision about your issue.

General Information: 888-466-2219

Frequently Asked Questions

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.
Yes. However, the DMHC must have on file a completed and signed DMHC Authorized Assistant Form. The DMHC cannot speak to anyone about your Independent Medical Review or Consumer Complaint unless we have your authorization to do so. Completion and submission of the DMHC Authorized Assistant Form tells the DMHC that it has your permission to speak with the person you have designated as your authorized assistant or representative.
The Department of Managed Health Care contracts with the Health Consumer Alliance, a group of local, community-based organizations that will give you free help with filing a grievance with your health plan. If you need more local, one-on-one assistance, please contact the Health Consumer Alliance’s Consumer Assistance Program at 1-888-804-3536.
  • If your health problem is urgent an IMR is usually decided within 7 days after the request qualifies for an IMR and the required documentation has been received by the DMHC’s Independent Medical Review Organization. This is called an expedited IMR. A health problem is urgent if it is a serious and immediate threat to your health. Your doctor must send us written documentation that your health problem is urgent.

  • If your health problem is not urgent, an IMR is usually decided within 30 days after we receive the supporting documentation from you, the doctor and the health plan.

Visit https://www.dmhc.ca.gov/FileaComplaint/FrequentlyAskedQuestions.aspx for more information.

Your health plan must cover emergency care wherever you receive it. If your plan does not pay the bill, file a complaint with your health plan. If you are not satisfied with your plan's decision, contact the Help Center.
Yes. Currently, the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) regulate Covered California health plans. At this time the DMHC regulates the vast majority of Covered California Health Plans. If you contact the DMHC and we find that your health plan is under the jurisdiction of CDI, we will help you contact the CDI.
Call your health plan and explain the problem. You can file a complaint with your health plan. If you are not satisfied with your plan's decision, you can contact the Help Center. You can also complain to the licensing agency that oversees the provider who gave you the care.
  • Your health plan may cancel your coverage if you or your employer did not pay your premiums. If this happens, call your plan right away and try to arrange payment.

  • A health plan can also cancel coverage if the member used fraud and deception to get services or violated the contract in other ways.

  • Your coverage may also end because your employer stops offering health coverage to employees.

  • If you think your coverage was cancelled because of your health condition or because you need medical care, contact the Help Center.
In approximately 60% of IMR cases, the health plan's denial of service was reversed by the health plan or overturned by the Independent Medical Review Organization and the enrollee received authorization for the requested service or treatment. If the IMR decision is in your favor, the health plan must authorize the service(s) or treatment(s) within five business days. The IMR is free, easy, and fast and in most cases, the IMR is decided within 30 days of IMR qualification and receipt of all required documentation. If you need more local, one-on-one assistance in filling out the IMR form, please contact the DMHC at 1-888-466-2219 or the DMHC's Consumer Assistance Program, Health Consumer Alliance, at 1-888-804-3536.
Try to keep your old health plan until you get a new health plan through a new job. Enroll in Federal COBRA/Cal-COBRA or an individual plan as soon as you can. You usually have to enroll within 60 days of being notified of your Federal Cobra/CAL-COBRA rights. You may also contact Covered California toll free at 1-800 300-1506 for health care coverage options.
It means that your plan believes that the service you or your doctor requested is not appropriate for your medical condition, or the plan wants you to try a different treatment. Sometimes doctors and health plans do not agree on what is medically necessary.
Call your health plan and ask for an expedited review. You can stay in the hospital until your review is completed. However, you may have to pay the bill if the review is in the plan's favor. Your plan must give you a decision within 3 days, or sooner if needed. You should also call the Help Center and say your problem is urgent. If you are in a Medicare Advantage plan, contact Livanta at 1-877-588-1123. If you are in a Medi-Cal managed care plan, call the Medi-Cal Ombudsman at 1-888-452-8609.
You will need to change to a new doctor (or hospital) that is in your health plan. Contact your health plan for a list of doctors or hospitals. You should ask your old doctor to send your medical records to your new doctor. In some cases, you can continue with your same doctor or hospital for some time.
The Help Center will send you a letter saying that your problem does not qualify. If this happens, the Help Center will review your case through its Consumer Complaint process and send you a written decision within 30 days. You do not need to send in another form.
If the IMR is decided in your favor, your health plan must authorize the service or treatment.
Usually, a doctor, hospital, or other provider in your health plan's network can bill you only for your deductible, co-pay, or co-insurance. If you get a bill for another cost, call the billing office that sent you the bill and ask them to explain the bill to you. If you disagree, file a complaint with your plan. If you are not satisfied with your plan's decision, contact the Help Center.
Complete and submit the Independent Medical Review Application/Complaint Form online by mail or fax. The DMHC will review your Independent Medical Review Application/Complaint Form to decide if the service you want is a covered benefit. If the service is not covered, we will inform you that you do not qualify for an IMR and your complaint will be reviewed as a Consumer Complaint.

The Consumer Complaint process assists consumers in resolving issues with their health plans, including the following types of complaints:

  • Improper denial or delay in settlement of a claim.
  • Health claims that have been denied by the health plan because the service or treatment is not covered under the contract.
  • Legal interpretations of policy language, provisions, and terms.
  • Bad faith allegations and other demands for extra payments under the health insurance contract.
  • Alleged illegal cancellation or termination of a policy.
  • Alleged misrepresentation by an agent, broker, or solicitor.
  • Alleged theft of premiums paid to an agent, broker, or solicitor.
  • Issues with providers, medical groups and pharmacies.
An IMR is a review of your case by independent doctors who are not part of your health plan. You have a good chance of receiving the service(s) or treatment(s) you need by requesting an IMR. Approximately 60% of enrollee’s that submit IMR requests to the DMHC receive the service(s) or treatment(s) they requested. If the IMR is decided in your favor, your plan must authorize the service(s) or treatment(s) you requested. IMR’s are free to enrollees.

If your health plan denies your request for medical services or treatment, you can file a complaint (grievance/appeal) with your plan. If you disagree with your plan's decision, or it has been at least 30 days since you filed a complaint with your health plan you can request an IMR with the DMHC. The DMHC staff will determine whether your issue qualifies for an IMR.

A request will qualify for an IMR if your Health Plan:

  • Denies, modifies, or delays a service or treatment because the health plan determines it is not medically necessary.
  • Will not cover an experimental or investigational treatment.
  • Will not pay for emergency or urgent medical services that you have already received.
See sections 1374.30 and 1370.4 of the Knox-Keene Health Care Service Plan Act of 1975 (part of the California Health and Safety Code). You can also see the rules that the DMHC has created for the IMR process. They are in Title 28 of the California Code of Regulations in sections 1300.74.30 and 1300.70.4. Click this link to review health care laws.
  • Medicare enrollees.
  • Medi-Cal fee-for-service members (Medi-Cal members who are not in a managed care plan).
  • Members of self-insured, self-funded, and ERISA plans.
  • An enrollee that is disputing a worker’s compensation claim.
Yes. Your name, medical records, and all other personal medical information are kept private and confidential under California law. IMR decisions are public, but they do not show the names of any patients, doctors, or facilities.

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