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.

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.

During DMHC’s IMR an outside doctor who is not part of L.A. Care will review your case.
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 has already happened, you cannot ask for an IMR. In this case, the State Hearing has the final say.

Complaints and appeals related to Medi-Cal Rx pharmacy benefits are not handled by L.A. Care.
You can submit complaints and appeals about Medi-Cal Rx pharmacy benefits by visiting the Medi-Cal Rx website or by calling 1-800-977-2273 (TTY 800-977-2273 and press 5 or 711). However, complaints and appeals related to pharmacy benefits not subject to Medi-Cal Rx may be eligible for an Independent Medical Review.
If you do not agree with a decision related to your Medi-Cal Rx pharmacy benefit, you may ask for a State Hearing. Medi-Cal Rx pharmacy benefit decisions are not subject to the IMR process with the DMHC.