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Questions and Answers About IMR

Can I get an IMR if I am in Medi-Cal?

  • Yes. If you are in a Medi-Cal managed care plan, you can apply for an IMR.
  • You can also ask for a Medi-Cal State Hearing - call 1-800-952-5253. This is a review of your problem by the state.
  • Note:  If you start the Medi-Cal State Hearing process you cannot get an Independent Medical Review from the Help Center. But 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.

Who cannot get an IMR?

  • If you have Medicare, you cannot get an IMR. If you are in Medicare Advantage, you must file an appeal with the health plan. Or you can call the Health Services Advisory Group at 1-818-409-9229. HSAG is an organization that has a contract with Medicare to help members with appeals.
  • Medi-Cal fee-for-service members (Medi-Cal members who are not in managed care) cannot get an IMR.
  • Members of self-insured or self-funded group health plans cannot get an IMR. These are health plans that are usually through a large employer. The employer pays doctors, hospitals, and other providers directly for employees' health care, instead of paying a premium to an HMO or other insurance company to provide the health care.

What if my plan says the service I want is not covered in my benefit package?

Complete and mail the IMR application anyway. The Help Center will review your IMR application to decide if the service you want is covered. If the service is not covered, we will tell you that you cannot get an IMR.

Can I get an IMR if my plan will not pay for the medicine I think I need?

If your plan covers prescription drugs and it says that the drug you asked for is not medically necessary or is experimental or investigational, you can apply for an IMR.

What does it mean if my health plan says a service is not medically necessary?

It means that your plan thinks that the service you asked for is not appropriate for your medical condition, or the plan wants you to try a different treatment. Sometimes doctors and health plans do not agree on what is medically necessary.

What happens if my problem does not qualify for an IMR?

The Help Center will send you a letter saying that your problem does not qualify. If this happens, the Help Center will review your case through its regular complaint process and send you a written decision within 30 days. You do not need to send in another form.

How long does an IMR take?

  • If your health problem is urgent an IMR is usually decided within 3-7 days. This is called an expedited IMR. A health problem is urgent if it is a serious and immediate threat to your health. Your doctor must send us written documentation that your health problem is urgent.
  • If your health problem is not urgent, an IMR is usually decided within 30 days after we receive the supporting documentation from you, the doctor and the health plan.
  • An IMR can take longer if we do not receive all of the medical records that we need from you. If you are seeing a doctor who is not in your health plan's network, it is important that you send us your medical records from that doctor. Your health plan is required to get copies of your medical records from doctors who are in the network.

What happens if the IMR is decided in my favor?

If the IMR is decided in your favor, your health plan must provide the service or treatment. The Help Center will make sure that you receive the service or treatment.

Will my medical condition and treatment stay private?

Yes. Your name, medical records, and all other personal medical information are kept private and confidential under California law. IMR decisions are public, but they do not show the names of any patients, doctors, or facilities. You can read past IMR decisions.

Where can I read the IMR laws?

See sections 1374.30 and 1370.4 of the Knox-Keene Health Care Service Plan Act of 1975 (part of the California Health and Safety Code). You can also see the rules that the DMHC has created for the IMR process. They are in Title 28 of the California Code of Regulations in sections 1300.74.30 and 1300.70.4. You can read these and other health care laws.