Eligibility for an IMR

If you want to request an Independent Medical Review, the dispute must involve a request for services from a managed health care service plan. The following groups are not eligible for the Department of Managed Health Care Independent Medical Review Program.

• Medicare beneficiaries, including members of Medicare + Choice managed care plans, should contact Medicare at 1-800-633-4227, and request an appeal. Further information about Medicare is also available at http://www.medicare.gov/publications/pubs/nonpdf/appeals.asp



• For Medi-Cal managed care enrollees, the IMR process is available if the enrollee has not already participated in the Fair Hearing process regarding the disputed treatment or service. Enrollees who would like to opt for the Fair Hearing process should contact the Department of Health Care Services Fair Hearing Division at 1-888-452-8609.



• The Department's IMR process is not available to Medi-Cal fee-for-service beneficiaries. Medi-Cal fee-for-service beneficiaries must use the State Fair Hearing Process. Contact the Department of Health Services at 1-800-952-5253.



• The Department's IMR process is not available to PPO enrollees (except Blue Cross & Blue Shield). Contact the California Department of Insurance at 1-800-927-HELP.



• The Department’s IMR process is not available to enrollees in a self-insured ERISA plan. Contact the Department of Labor, Pension/Welfare Benefits Division at 1-866-275-7922.



• The Department’s IMR process is not available to enrollees disputing a Worker's Compensation Claim. Contact the Department of Industrial Relations at 1-800-736-7401.



• An application for an Independent Medical Review to the Department of Managed Health Care must usually be submitted within 6 months of receiving the denial from the HMO.

The type of disputed service must be a covered benefit under your HMO benefits. For example, if the HMO denied hospitalization for alcohol detoxification because such alcohol and drug dependency treatments are excluded benefits, the contract does not cover the services, even if hospitalization is medically necessary.