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HMO says no? How to get help

If your HMO refuses to cover you for medical services, you can seek help from the state government.

The California Department of Managed Health Care (DMHC) recently created the Independent Medical Review program, which allows patients who have been denied treatment or medical care to have those decisions reviewed by physicians or other appropriate medical professionals who have no affiliation with their health plans. The DMHC ensures that California patients have access to high-quality health care and makes sure that the doctor-patient relationship is always secure.

The Independent Medical Review program provides patients with an impartial review of:

  • Health plan denials, delays or modifications of services based upon the finding that they are not medically necessary
  • Health plan denials of experimental or investigational treatment
  • Health plan denials of reimbursement for emergency or urgent medical services

The program contracts with several independent medical review organizations. The independent reviewer considers a patient’s medical records, health plan denial and grievance letters, supporting documentation from the patient and treating physician(s) and other appropriate documents.

The decision of the reviewer is sent to the Department of Managed Health Care, the patient, the treating physician and the health plan. The health plan must comply with the decision of the reviewer.

There is no charge or processing fee for an independent medical review. The process will be completed within 30 days; if there is a medical necessity, this time frame will be shortened. However, in most circumstances, patients are required to participate in their health plan’s grievance process prior to requesting an independent medical review.
If you have been denied care from your health plan, call the HMO Help Center at (888) HMO-2219.