Did You Know? Physicians can help patients appeal medical necessity denials

July 12, 2021

Both the California Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) have independent medical review (IMR) processes through which patients can request an external medical review of any health plan or insurer decision to deny, modify or delay treatment based on a lack of medical necessity or investigational or experimental denials.

Under California law, all patients enrolled in fully insured commercial products regulated by DMHC or CDI have the right to appeal these denials through the regulator’s IMR process.

The goal of the legislature in mandating the availability of this formal IMR process was to ensure that appropriate and equitable medical necessity decisions are made and to increase public confidence in the managed care system.

Both the DMHC and CDI have established IMR processes that are accessible on the regulator websites.

According to the 2020 DMHC Annual Report, 68% of consumers who submitted an IMR request received the service or treatment they requested. CDI’s Interactive Independent Medical Review Statistics also show that 53% of IMRs filed through CDI were decided in favor of the patient.

During an IMR, independent physicians that do not work for the health plan will examine the case to see if the denial was appropriate or if the enrollee should receive the requested service or treatment. If it is determined that the health plan/insurer’s denial was not appropriate, the plan/insurer must cover the requested service or treatment.

Before filing for an IMR, patients must first file a grievance with their plan/insurer. However, if the patient does not agree with the health plan/insurer's response or the payor takes more than 30 days to fix the problem, the patient can file for an IMR through the DMHC Help Center or through CDI, depending on which entity regulates the patient’s insurer. Typically, DMHC regulates all HMOs as well as the Blue Shield and Anthem Blue Cross PPOs, while CDI regulates the remaining PPO products.

It’s also important to know that physicians can assist their patients in filing for IMR or can file on the patient’s behalf. Patients who wish to designate a physician or another person to file on their behalf must complete and sign the required DMHC Authorized Assistant Form or for CDI regulated products must sign the Designation of IMR Agent (last page of the IMR form).

IMR requests must be made within six months unless the regulator approves an extension due to special circumstances. Applying for an IMR is free.

For more information about how physicians can assist patients in seeking an IMR, see California Medical Association health law library document #7155, “Independent External Medical Review.”



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