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Medi-Cal Member Handbook / Benefit Year 2006-2007L.A. Care/Community Health Plan does nothandle grievances about your Medi-Caleligibility. For these types of questions, callyour DPSS eligibility worker toll-free at 1-877-481-1044.How to appeal health care servicesdenied or delayed as not medicallynecessaryIf you believe a health care service has beenwrongly denied, changed, or delayed byL.A. Care or Community Health Plan because itwas found not medically necessary, you mayrequest an Independent Medical Review (IMR)from DMHC. This is known as a disputed healthcare service.You have up to six months from the date ofdenial to file an IMR. You will receive informationon how to file an IMR with your denial letter.You may reach DMHC toll-free at 1-888-HMO-2219 or 1-888-466-2219.There are no fees for an IMR. You have the rightto provide information to support your request foran IMR. After the IMR application is submitted, adecision not to take part in the IMR process maycause you to lose certain legal rights to pursuelegal action against the plan.You may still request a State Fair Hearing if yourequest an IMR. However, you will not be able touse the IMR process if you have requested a StateFair Hearing. Go to “State Fair Hearing” below tofind out more.When to File an Independent MedicalReview (IMR)You may file an IMR if you meet the followingrequirements:• Your doctor says you need a health care servicebecause it is medically necessary and it isdenied; or• You received urgent or emergency servicesdetermined to be necessary and they were denied;or• You have seen a network doctor for the diagnosisor treatment of the medical condition,even if the health care services were not recommended.• The disputed health care service is denied,changed or delayed by Community HealthPlan based in whole or in part on a decisionthat the health care service is not medicallynecessary, and• You have filed a grievance with CommunityHealth Plan and the health care service is stilldenied, changed, delayed or the grievance remainsunresolved after 30 days.You must first go through the Community HealthPlan grievance process, before applying for anIMR. In special cases, the DMHC may notrequire you to follow the Community Health Plangrievance process before filing an IMR.The dispute will be submitted to a DMHCmedical specialist if it is eligible for an IMR. Thespecialist will make an independent decision onwhether or not the care is medically necessary.You will receive a copy of the IMR decision fromDMHC. If it is decided that the service is medicallynecessary, Community Health Plan willprovide the health care service.Non-urgent casesFor non-urgent cases, the IMR decision must bemade within 30 days. The 30-day period startswhen your application and all documents arereceived.31Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273
Medi-Cal Member Handbook / Benefit Year 2006-2007Urgent casesIf your grievance is urgent and requires fastreview, you may bring it to DMHC attention rightaway. You will not be required to participate inthe health plan grievance process for more thanthree business days before bringing an urgentIMR.For urgent cases the IMR decision must be madewithin three business days from the time yourinformation is received.Examples of urgent cases include:• Severe pain• Potential loss of life, limb or major bodilyfunction• Immediate and serious deterioration of yourhealthIMRs for Experimental and InvestigationalTherapies (IMR-EIT)You can request an IMR-EIT through the DMHCwhen a medical service, drug or equipment isdenied because it is experimental or investigationalin nature. Community Health Plan willnotify you in writing that you may request anIMR-EIT within five days of the decision to denycoverage. You have up to six months from thedate of denial to file an IMR-EIT. You may giveinformation to the IMR-EIT panel. The IMR-EITpanel will give you a written decision within 30days from when your request was received. Ifyour doctor thinks that the proposed therapy willbe less effective if delayed, the decision will bemade within seven days of the request for anexpedited review. In urgent cases the IMR-EITpanel will give you a decision within threebusiness days from the time your information isreceived.You may file an IMR-EIT if you meet thefollowing requirements:1. You have a very serious condition that is“life-threatening” or “debilitating” (for example,terminal cancer).2. Your doctor must certify that:• The standard treatments were not or willnot be effective, or• The standard treatments were not medicallyappropriate, or• The proposed treatment will be the mosteffective.3. Your doctor certifies in writing that:• A drug, device, procedure or other therapyis likely to work better than thestandard treatment• Based on two medical and scientificdocuments, the recommended treatmentis likely to work better than the standardtreatment.4. You have been denied a drug, equipment,procedure or other therapy recommended orrequested by your doctor.5. The treatment would normally be covered asa benefit, but Community Health Plan has determinedthat it is experimental orinvestigational in nature.To find out more, get help with the IMR or IMR-EIT process, or ask for an application form,please call Community Health Plan.You do not need to participate in L.A. Care’s orCommunity Health Plan’s grievance processbefore asking for an IMR of a decision to denycoverage on the basis that the treatment is experimentalor investigational in nature.32Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273
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