Member Handbook - Los Angeles County Department of Health ...

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