An IMR is when an outside doctor who is not related to your health plan reviews your case.
If you want an IMR, you must first file an appeal with L.A. Care.
If you do not hear from your health plan within 30 calendar days, or if you are unhappy with your health plan’s decision, then you may then request an IMR.
You must ask for an IMR within 6 months from the date on the notice telling you of the appeal decision but you only have 120 days to request a State Hearing so if you want an IMR and a State hearing file your complaint as soon as you can.
Remember, if you ask for a State Hearing first, and the hearing has already happened, you cannot ask for an IMR. In this case, the State Hearing has the final say.
You may be able to get an IMR right away without filing an appeal first. This is in cases where your health problem is urgent.
If your complaint to the California Department of Managed Health Care (DMHC) does not qualify for an IMR, DMHC will still review your complaint to make sure L.A. Care made the correct decision when you appealed its denial of services.
L.A. Care has to comply with DMHC’s IMR and review decisions.
How to ask for an IMR
The term “grievance” is for “complaints” and “appeals”:
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at L.A. Care Member Services at 1-888-839-9909 (TTY 711) and use your health plan’s grievance process before contacting the DHMC.
Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the DHMC for assistance.
You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.
The DMHC's website has complaint forms, IMR application forms and instructions online. The department also has a toll-free telephone number 1-888-466-2219 and a TDD line (1-877-688-9891) for the hearing and speech impaired.