CALIFORNIA - Pacificare Health Systems

PART A
118
Overseeing Your Health Care
Provider denying the request for Experimental or
Investigational treatment.
In the case of determinations that a Disputed Health
Care Service is not Medically Necessary, PacifiCare
will provide you with an IMR application form with
any disposition letter resolving your appeal of the
determination. Your application for IMR of a Disputed
Health Care Service may include information or
documentation regarding a Provider’s recommendation
that the service is Medically Necessary, medical
information that a service received on an urgent care
or emergency basis was Medically Necessary, and
any other information you received from or gave
to PacifiCare or its Participating Providers that you
believe is relevant in support of your position that the
Disputed Health Care Service was Medically Necessary.
Completed applications for IMR should be submitted
to the DMHC. You pay no fee to apply for IMR. You,
your Physician, or another designated representative
acting on your behalf may request IMR. If there is
any additional information or evidence you or your
Physician wish to submit to the DMHC that was not
previously provided to PacifiCare, you may include this
information with the application for IMR. The DMHC
fax number is (916) 229-0465. You may also reach the
DMHC by calling 1-888-HMO-2219.
Accepted Applications for Independent Medical
Review
Upon receiving your application for IMR, the DMHC
will review your request and notify you whether your
case has been accepted. If your case is eligible for
IMR, the dispute will be submitted to an Independent
Medical Review Organization (IRO) contracted
with the DMHC for review by one or more expert
reviewers, independent of PacifiCare, who will make an
independent determination of whether or not the care
should be provided. The IRO selects an independent
panel of medical professionals knowledgeable in the
treatment of your condition, the proposed treatment
and the guidelines and protocols in the area of
treatment under review. Neither you nor PacifiCare will
control the choice of expert reviewers. PacifiCare must
provide the following documents to the IRO within
three (3) business days of receiving notice from the
DMHC that you have successfully applied for an IMR:
1. The relevant medical records in the possession of
PacifiCare or its Participating Providers;
2. All information provided to you by PacifiCare
and any of its Participating Providers concerning
PacifiCare and Provider decisions regarding
your condition and care (including a copy of
PacifiCare’s denial notice sent to you);
3. Any materials that you or your Provider submitted
to PacifiCare and its Participating Providers
in support of the request for the health care
services;
4. Any other relevant documents or information
used by PacifiCare or its Participating Providers
in determining whether the health care service
should have been provided and any statement by
PacifiCare or its Participating Providers explaining
the reasons for the decision. The Plan shall
provide copies of these documents to you and
your Provider unless any information in them is
found by the DMHC to be privileged.
If there is an imminent and serious threat to your
health, PacifiCare will deliver the necessary information
and documents listed above to the IRO within 24 hours
of approval of the request for IMR.
After submitting all of the required material to the IRO,
PacifiCare will promptly issue you a notification that
includes an annotated list of the documents submitted
and offer you the opportunity to request copies of
those documents from PacifiCare.
If there is any information or evidence you or your
Provider wish to submit to the DMHC in support of
IMR that was not previously provided to PacifiCare,
you may include this information with your application
to the DMHC. Also as required, you or your Provider
must provide to the DMHC or the IRO copies of any
relevant medical records and any newly developed or
discovered relevant medical records after the initial
documents are provided and respond to any requests
for additional medical records or other relevant
information from the expert reviewers.
The Independent Medical Review Decision
The independent review panel will render its analysis
and recommendations on your IMR case in writing,
and in layperson’s terms to the maximum extent
practical, within 30 days of receiving your request for
IMR and supporting information. The time may be
adjusted under any of the following circumstances: