2025 Medi-Cal Member Handbook

 

What To Do If You Do Not Agree With An Appeal Decision

If you requested an appeal and got a NAR letter telling you we did not change our decision, or you never got a NAR letter and it has been past 30 days, you can:

  • Ask for a State Hearing from the California Department of Social Services (CDSS), and a judge will review your case. CDSS’ toll-free telephone number is 1-800-743-8525 (TTY 1-800-952-8349). You can also ask for a State Hearing online at the CDSS website. You can find more information in the State Hearings section of this online handbook.
  • File an Independent Medical Review/Complaint form with the Department of Managed Health Care (DMHC) to have L.A. Care’s decision reviewed. Or ask for an Independent Medical Review (IMR) from the DMHC. If your complaint qualifies for DMHC’s Independent Medical Review (IMR) process, an outside doctor who is not part of L.A. Care will review your case and make a decision that L.A. Care must follow. 

    You can find the Independent Medical Review/Complaint form and instructions online at the DMHC’s website. You can also call DMHC’s toll-free telephone number at 1-888-466-2219 (TDD: 1-877-688-9891).

You will not have to pay for a State Hearing or an IMR.

You are entitled to both a State Hearing and an IMR. But if you ask for a State Hearing first and the hearing to address your specific issues has already happened, you cannot ask for an IMR with DMHC on the same issues.
In this case, the State Hearing has the final say. But you may still file a complaint with DMHC if the issues do not qualify for IMR, even if the State Hearing has already happened. 

Complaints and appeals related to Medi-Cal Rx pharmacy benefits are not handled by L.A. Care. To submit complaints and appeals about Medi-Cal Rx pharmacy benefits, visit the Medi-Cal Rx website or call 1-800-977-2273 (TTY 800-977-2273 and press 7 or 711). Complaints and appeals related to pharmacy benefits not subject to Medi-Cal Rx may be eligible for an Independent Medical Review (IMR).

If you do not agree with a decision related to your Medi-Cal Rx pharmacy benefit, you may ask for a State Hearing. You cannot ask DMHC for an IMR for Medi-Cal Rx pharmacy benefit decisions.