An analysis of the results of Independent Medical Reviews (IMR) by the California Department of Managed Health Care shows that if a patient appeals a denial, about half the time, they succeed in getting that decision overturned or withdrawn.
The California Department of Managed Health Care is one of two agencies regulating insurance companies. It focuses on Health Maintenance Organizations (HMOs). Here's how it describes the IMR process:
“The Affordable Care Act provides millions of Americans who were previously denied health coverage the ability to purchase a plan," says Marta Green, Deputy Director of Communications with the California Department of Managed Health Care. "The Independent Medical Review process guarantees that health plan enrollees get the medically necessary care they need.”
Take a look at the success rates of patient appeals through the California Department of Managed Health Care from 2006 through 2012. The insurance companies highlighted in the breakdown are ones that have more than 400,000 people enrolled.
Attach copies of letters or other documents about the treatment or service that your health plan denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.
If you have questions about filling out your application form, call the Help Center at 1-888-466-2219 or (TDD) 1-877-688-9891. There is no charge for this call.
What Happens Next: The Help Center will review your application and send you a letter within 5 days. This letter will tell you if you qualify for an IMR. The IMR decision is then made within 30 days, or within 3 to 7 days if your problem is urgent.
If the IMR is decided in the patient's favor, the health plan must provide the service or treatment. The Help Center will make sure that the patient receives the service or treatment.