In most cases, you must begin your health plan's complaint process before you apply for an Independent Medical Review (IMR)/Complaint with the Department of Managed Health Care (DMHC). Your plan is required to give you a decision within 30 days or within 3 days if your problem is an immediate and serious threat to your health; if it does not, you may seek IMR.
If your plan denied your treatment because it was experimental or investigational, you do not have to take part in your plan's complaint process before you apply for an IMR with the DMHC.
You must apply for an IMR/Complaint with the DMHC within 6 months after your health plan sends you a written decision about your issue.
How to Apply
- Fill out the Independent Medical Review/Complaint Form .
- Attach copies of letters or other documents about the treatment or service that your health plan denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.
- If you have questions about filling out your application form, call the Help Center at 1-888-466-2219 or (TDD) 1-877-688-9891. There is no charge for this call.
- Mail or fax your form and any attachments to:
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
What Happens Next?
The Help Center will review your application and send you an acknowledgement of receipt letter within 5 days. The IMR/Complaint decision is then made within 30 days, or within 3 to 7 days if your problem is urgent.
Common Consumer Q&A
Search IMR Decisions
Questions and Answers about Legal Actions
What kinds of complaints does the Help Center handle?
- You can’t get the medicine or treatment you need.
- You have to wait too long for a referral, authorization, test, or appointment.
- You are being sent home from the hospital too soon.
- You have a problem with a bill, claim, or co-pay.
- You received a bill for emergency or urgent care.
- You cannot get services in your language.
- Your doctor or hospital is no longer with your health plan.
Does the Help Center act as my attorney?
No. The Help Center does not give legal advice or act as your attorney. We will review your issue through our IMR or Consumer Complaint process and let you know if your health plan must provide the service or item you are requesting.
How will my complaint be decided?
The IMR will be decided by qualified, independent clinicians who are not employed by your health plan. Your complaint will be decided by experienced analysts, nurse consultants or lawyers. The Help Center will send you and your health plan a letter that explains our decision. If the complaint is decided in your favor, we will require your health plan to provide or pay for the service, or do whatever is needed to resolve the complaint. If the complaint is not decided in your favor, you cannot appeal the decision. However, you may still be able to take legal action and may want to speak with a private attorney.