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Appealing Denied Health Care Services Through The Calif. Dept. Of Insurance

  

An analysis of the results of Independent Medical Reviews (IMR) by the California Department of Insurance shows that if a patient appeals a denial, about 45% of the time, they succeed in getting that decision overturned or withdrawn.

The California Department of Insurance is one of two agencies regulating insurance companies in the state. It focuses on Preferred Provider Organizations (PPOs).

An Independent Medical Review (IMR) allows an impartial panel of medical professionals to review denials involving medical necessity of a treatment, an experimental treatment  or a denial for emergency services. 

The IMR could overturn the the insurer's decision. This means the insurance company has to take immediate action to approve the patient's request for service. The IMR can also uphold the denial or the insurance company can withdraw its decision.


Click here to see an interactive graphic on IMRs from the California Department of Insurance

Source: California Department of Insurance

*The California Department of Insurance is one of two agencies regulating insurance companies in the state. CDI mostly deals with Preferred Provider Organizations (PPOs).


Steps on how to apply for an IMR:

Application for Independent Medical Review

Notification You or any person you have designated may request an IMR if you disagree with a health insurer's decision regarding a disputed health care service that has been determined not to be medically necessary or has been denied as experimental or investigational. Your insurance company is required to send you an IMR application with its denial letter. If you do not receive an application from your insurance company, you can request one from the CDI by calling 1-800-927-HELP or by completing an IMR Application form (PDF).

The Agreement Since making a request for an IMR is voluntary, you must give written consent indicating that you wish to participate in the IMR program. The application form includes a consent statement which when signed gives your permission to obtain any necessary medical records in order to proceed with the IMR.

Eligibility When your completed application with any additional information is received, the CDI will determine if your request qualifies for the IMR program. If your request does qualify, you will be notified. If your request does not qualify for the IMR program, then your claims review request will be referred to the complaint/mediation program within the CDI.

The Review Process When your request qualifies as an IMR, the case is then sent to the IMR organization designated by the CDI. The CDI notifies the health insurance company involved and requires them to provide the IMR organization with copies of all documents necessary to conduct the IMR. In most cases, your insurance company must provide all relevant documents including medical records to the IMR organization within three business days. The IMR organization is required to complete its review in writing within 30 days.

The Determination Once the IMR organization has made its determination, the written determination will be provided to you, to your insurance company, and to the Insurance Commissioner. The determination must contain your medical condition, the important documents reviewed, and the findings that are relevant to your request.

The Sixth Step Implementation. Upon receiving the IMR determination, the Insurance Commissioner adopts the recommendation from the IMR organization immediately. A written decision will be issued by the CDI to you and to your insurance company explaining that the recommendation is binding on the insurance company.

Source: California Department of Insurance