Friday, May 2, 2025
DMHC Fines Blue Cross of California Partnership Plan, Inc. $550,000 for Delaying Medically Necessary Care
(Sacramento) – The California Department of Managed Health Care (DMHC) took enforcement action today, including a $550,000 fine, against Blue Cross of California Partnership Plan, Inc. for failing to timely implement an Independent Medical Review (IMR) determination, delaying a health plan member’s medically necessary treatment.
“California health plan members have the right to medically necessary treatment as soon as they need it,” said DMHC Director Mary Watanabe. “The health plan had an obligation under the law to provide the requested services to the member, and the continued unnecessary delays caused by the plan were unacceptable. California’s Department of Managed Health Care will continue to protect health plan members quality of care in our state.”
INDEPENDENT MEDICAL REVIEWS: Californians enrolled in health plans regulated by the DMHC have the right to appeal their health plan's decision by applying for an Independent Medical Review, also called an IMR, if their plan denies, changes, or delays their request for medical services, denies payment for emergency treatment or refuses to cover an experimental or investigational treatment. During an IMR, doctors who are independent and do not work for the health plan will examine the case to see if the health plan appropriately denied services, or if the member should receive the requested service or treatment. If it is determined that the health plan should not have denied the member's request, the plan must cover the service or treatment. California law requires health plans to authorize the services within five working days of receiving an IMR determination accepted by the Department.
BACKGROUND: In this case, a health plan member requested an in-home therapy evaluation and in-home therapy services for a medical condition. The plan denied the member’s request, and the member contacted the DMHC Help Center to request an IMR. The independent reviewer determined the in-home evaluation and therapy were medically necessary and overturned the plan’s denial.
The Department adopted the IMR determination and notified the plan. The plan acknowledged the IMR determination and authorized the in-home evaluation, but it did not include the in-home therapy services in its authorization letter to the health plan member. The member received authorization for in-home therapy 59 days after the IMR decision, making the plan 54 days late. The plan admitted the delay was due to a processing error.
WHAT MEMBERS NEED TO KNOW: The DMHC encourages health plan members experiencing issues with their health plan, including denials, delays or modifications of requested health care services, to file a complaint, also called an appeal or grievance, with their health plan. If the member does not agree with their health plan's response or the plan takes more than 30 days to respond to the grievance, the member should contact the DMHC Help Center. If a health plan member is experiencing an urgent issue, they should contact the DMHC Help Center immediately.
Health plan members can file a complaint or apply for an Independent Medical Review with the DMHC Help Center at www.DMHC.ca.gov or call 1-888-466-2219.
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About DMHC:
The DMHC protects the health care rights of more than 29.8 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted approximately 2.9 million Californians to resolve complaints and issues with their health plan. The DMHC Help Center provides assistance in all languages and all services are free. For more information visit www.DMHC.ca.gov or call 1-888-466-2219.