Review by Governmental Agencies. The following is a notice that the HMO is required to provide to Members that tells how to contact the HMO and the Department of Managed Health Care. A Member has the right to submit unresolved Complaints and Appeals to the California Department of Managed Health Care for review after either completing the complaints and appeals process described above or participating in the process for at least 30 days. “The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your plan at 0-000-000-0000 and use the plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unsolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department has a toll-free telephone number 0-000-XXX-0000 and a TDD line 0-000-000-0000 for the hearing and speech impaired. The department’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online. INDEPENDENT MEDICAL REVIEW Members have the right to an independent review of decisions by the HMO to deny, modify or delay coverage for health care service(s) based on Medical Necessity (Disputed Health Care Services). Members have the right to an independent medical review of decisions by the HMO to deny coverage for health care services which have been determined by the HMO to be excluded as Experimental and Investigative. Additional information about treatments which will not be excluded as Experimental and Investigative can be found under item G Transplant Benefits and Item X Additional Benefits – Clinical Cancer Trials, in the Covered Benefits section of the EOC. Section A below describes how Members may request Independent Medical Review for certain Experimental...
Review by Governmental Agencies. The following is a notice that the HMO is required to provide to Members that tells how to contact the HMO and the Department of Managed Health Care. A Member has the right to submit unresolved Complaints and Appeals to the California Department of Managed Health Care for review after either completing the complaints and appeals process described above or participating in the process for at least 30 days. "The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your plan at 1-800-756- 7039 and use the plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unsolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department has a toll-free telephone number 0-000-XXX-0000 and a TDD line 0-000-000-0000 for the hearing and speech impaired. The department’s Internet Web site (xxxx://xxx.xxxxxxx.xx.xxx) has complaint forms, IMR application forms and instructions online."
