How To Contest A Medical Insurance Denial In California

The number of contested denials handled by the California Department of Managed Health Care has nearly tripled over the past five years — from roughly 1,500 in 2012 to more than 4,200 in 2016.

If you have an insurance issue in California there are a few steps to the process. We’ve compiled information from Department of Managed Health Care guides to try and make that process clearer. Still, it’s still also a good idea to call the DMHC’s Help Center at 888-466-2219 if you have questions on how to file.

1. File a grievance with your insurance plan

Most plans have a form or phone number on their websites, or include the information in their enrollment packets

Your plan is legally required to respond within 30 days, or sooner if there is an immediate threat to your health. If your plan does not respond by the deadline — or if you are not satisfied with the decision — you can take your case to the California Department of Managed Health Care. You can only take this step if your plan is one of the 120 regulated by the DMHC.

2. Fill out an application

After filing a grievance, fill out this form at the DMHC website. You’ll need copies of letters and other documents related to the treatment or service that your health plan denied

3. DHMC classifies your case

Based on your application, the DMHC will decide if your case is a standard complaint,  or if it requires an Independent Medical Review. Here’s the difference:

• A consumer complaint is a general complaint about your plan, a provider, or a medical group. It can be about poor treatment, getting discharged from the hospital early, appointment delays or other general service complaints.

• An independent medical review (IMR) is about a specific service that your plan denied because it was deemed medically unnecessary or experimental. IMRs are reviewed by doctors who are not affiliated with any plan, and the doctors are required to use the most updated scientific evidence available.

4. Wait for a response

The Help Center will let you know that they received your form within five days. Then they have 30 days to complete the IMR or Complaint decision, or three to seven days if your problem is urgent.

5. Receive Care

If the IMR process is determined in your favor, your plan must cover the denied service. In nearly 69 percent of cases, IMR applicants receive the originally denied service, either because the plan reverses its decision after the complaint is filed or because the IMR overturns the plan’s denial.

There are some exceptions. You can’t get an IMR if:

• You are a Medicare Advantage enrollee. But you can call the Health Services Advisory Group (HSAG) at 1-818-409-9229.
• You are in a self-insured or self funded group of health plans
• You are in Medi-Cal Fee for Service (not managed care

If you are in Medi-cal, you can also ask for a Medi-Cal State Hearing by calling 1-800-952-5253. If you have had a Medi-Cal State Hearing you cannot get an Independent Medical Review. If you get an Independent Medical Review from the Help Center and you are not satisfied with the result, you can still get a Medi-Cal State Hearing, according to the DMHC