If you have traditional health insurance, review of any grievance you may have with your insurer over health care services starts with your insurer’s or its contracting provider’s internal grievance review process. Further review is afforded by your state Department of Insurance, or in certain cases, by Independent Medical Review Organizations. Your rights in each of these successive stages are dependent, to some extent, on your full participation in the preceding stage, so it is important that you review all of the following information and hire a personal injury lawyer if necessary.
Step 1: Your Plan’s Grievance Procedure:
Generally, before you are entitled to further review of your dispute with your insurer, you must file your grievance with your insurer’s internal grievance review process. If your grievance is one for which you are entitled to Department of Insurance review (see Step 2A), you must complete the insurer’s internal review process or participate in it for a reasonable time. If your grievance is one for which you are entitled to Independent Medical Review (see Step 2B), you must complete the insurer’s internal review process or participate in that process for 30 days. (But see Exceptions to Insurer’s Internal Review Requirements). Although this might seem like a waste of time, you must do it to preserve your right to review by the Department of Insurance and your right to Independent Medical Review.
The Insurer’s Grievance Review System: Your insurer most likely maintains an internal grievance review procedure, often set forth in the terms of your policy. Contact your insurer and check your policy carefully to determine whether such review procedures exist and how to file your grievance. If the procedure for filing your grievance is set forth clearly in the policy, follow that procedure. Otherwise, file your grievance according to your insurer’s instructions.
Your healthcare provider, contracted with your insurer, may also maintain an internal grievance review procedure. Again, check your policy carefully and contact both the provider and your insurer to determine whether you must also participate in the contracting provider’s grievance review process, how to do so, and how that process works in relation to the insurer’s grievance review process.
For convenience, these interrelated insurer and contracting provider review processes are referred to together as the insurer’s internal grievance review process.
If for any reason you are unsure how to file your grievance, including if your insurer informs you that there is no internal review, if your insurer tells you to file your grievance in a manner different from the terms of the policy, if your insurer and its contracting provider tell you inconsistent things, or if your insurer or its contracting provider are not forthcoming in providing you with information on how to file your grievance, contact the Department of Insurance immediately and inform them of the situation. They will help you determine the correct way to file your grievance with your insurer or contracting provider, or they may permit you to proceed directly with Department Review or Independent Medical Review (See Step 2).
Exceptions to Insurer’s Internal Review Requirements: If your insurer does not maintain an internal grievance review process, if your grievance involves an imminent and serious threat to your health, such as severe pain, potential loss of life, limb, or major bodily function, or other similar serious conditions, or if you believe there are other compelling reasons to expedite review, you should submit your grievance to the Department with a request for early review on this basis at the same time as your submit your grievance to your insurer. (See Step 2).
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Experimental or Investigational Therapies: Your insurer must maintain an external review process to examine coverage decisions regarding experimental or investigational therapies for you if you meet all of five criteria:
you have a life threatening or seriously debilitating condition;
your physician certifies that standard therapies have been ineffective, would be medically inappropriate, or are not as beneficial as proposed therapies;
a physician contracted with your insurer has recommended a drug, device, or procedure and certified it is more beneficial than standard therapies OR a qualified physician not contracted with your insurer has requested such a therapy, and certified it is likely to be more beneficial, supported by medical and scientific documentary evidence;
you have been denied coverage by your insurer for the recommended therapy; AND
you would be covered for the therapy under your policy except for your insurer’s determination that said therapy is experimental or investigational.
Your insurer’s decision to delay, deny, or modify such therapies is subject to the Independent Medical Review process. (See Step 2B).
Step 2A: Review by California’s Department of Insurance:
All grievances not eligible for review by an Independent Medical Review Organization (See Step 2B) are eligible for regular review by the Department of Insurance. Generally, you must participate in your insurer’s internal grievance review process before you are entitled to Department Review.
When and How Can I Seek Department Review: After your insurer’s internal grievance review process has been completed, or your grievance has been pending for a “reasonable time”, whichever is sooner, you are entitled to submit your grievance to the Department of Insurance.
As a rule of thumb, if your grievance has been pending for 30 days without resolution, it has probably been pending for a “reasonable time”, and you should seek Department Review. Unlike Independent Medical Review, (see Step 2B), however, you do not have a statutory right to Department Review after 30 days, and the Department may require further participation in your insurer’s internal review process. On the other hand, if you believe your insurer is not reviewing your grievance in good faith, you should submit your grievance to the Department earlier than 30 days, accompanied by an explanation of why you believe further participation in your insurer’s review process should be excused.
If your insurer does not maintain internal grievance review procedures, if your grievance involves an imminent and serious threat to your health, such as severe pain, potential loss of life, limb, or major bodily function, or other similar serious conditions, or if you believe there are other compelling reasons to expedite review, you should submit your grievance to the Department with a request for early review on this basis at the same time as your submit your grievance to your insurer.
Contact the Department of Insurance to request further information on how to apply for Department Review and how that review is conducted.
Step 2B: The Department’s Independent Medical Review System:
The Independent Medical Review System is available anytime your insurer or its contracting provider denies, delays, or modifies health care services that are eligible for coverage and payment under your insurance contract, based in whole or in part on a finding that the services are not medically necessary. All grievances not eligible for Independent Medical Review are eligible for regular Department Review. If the Department finds that your grievance is not eligible for Independent Medical Review, it will be treated as a request for Department Review. (See Step 2A).
Independent Medical Review (“IMR”) is not available until you have completed, or participated for 30 days in your insurer’s internal grievance review process (See Step 1). If your insurer does not maintain an internal grievance review process, if your grievance involves an imminent and serious threat to your health, such as severe pain, potential loss of life, limb, or major bodily function, or other similar serious conditions, or if you believe there are other compelling reasons to expedite review, you should submit your grievance to the Department with a request for early IMR on this basis at the same time as your submit your grievance to your insurer. In cases of a serious and imminent threat to health, you will not be required to participate in the insurer’s internal grievance process for more than 3 days.
Effective Dates of Independent Medical Review: Every health insurance contract that is issued, amended, or delivered in California on or after January 1, 2000, must provide an insured with the opportunity to seek independent medical review by January 1, 2001.
What is Independent Medical Review?: IMR is conducted by an in-state medical review organization that is independent of any insurer doing business in this State. That organization, and all of its officers, directors, employees, and contracted experts must have no professional, familial, or financial affiliation with your insurer; your insurer’s officers, directors, employees; or any physician, physician’s medical group, or independent practice association involved in the dispute. IMR is limited to consideration of medical necessity issues and does not consider coverage decisions or other contractual issues. Coverage/contract aspects are reviewed by the Department of Insurance. (See Step 2A).
Criteria for Independent Medical Review: In addition to mandatory participation in the insurer’s grievance review process, you may apply for Independent Medical Review only if:
Your health care provider has recommended a health care service as medically necessary OR; you have received urgent or emergency care that your provider determined was medically necessary OR; you have been seen by an in-plan provider for the diagnosis or treatment of the medical condition for which you seek independent medical review (without the requirement that the in-plan provider recommend the disputed health care service); AND;
The disputed health care service has been denied, delayed, or modified by your insurer or one of its contracting providers, based in whole or in part on a decision that the services were not medically necessary.
Time to Apply for Review: You must apply to the Department of Insurance for independent medical review within 6 months of when the disputed service was recommended, when you saw the in-plan provider, when the service was denied, delayed, or modified, the date the disputed decision was upheld by your insurer’s internal grievance review, or the last date of participation in your insurer’s grievance process, whichever is latest. The 6 month period can be extended by the Insurance Commissioner if the circumstances warrant it.
The IMR Process: When your insurer provides a notice of decision after a grievance review that denies, modifies, or delays health care services, the insurer must provide you with an approved application form for Independent Medical Review, and a consent form for you to sign that allows the insurer to obtain the medical records necessary for the review (including from out-of-plan providers). There are no application or processing fees. If you do not receive an application from your insurer, or if you believe you are entitled to expedited review, contact the Department of Insurance to request an application form and information.
The Department of Insurance will review your request for Independent Medical Review expeditiously and immediately notify you if your request has been approved, or if not, the reasons for that decision. If your request is not approved, your request will be treated as an immediate request for Department review. (See Step 2A).
After the insurer receives notice from the Department of Insurance of your application for IMR, the insurer must provide within 3 days (or within 1 day in the case of an “imminent and serious” threat to health) all relevant medical records, documents, and information in its possession or its contracting providers’ possession. The insurer must send you an annotated list of documents submitted and offer you the opportunity to request copies.
You also have the right to supplement your application, directly or through your provider, with information or documentation that the disputed health care service is or was necessary.
The Notice of Decision: To the “maximum extent practicable”, the review organization must make a written determination, in lay-person’s language, within 30 days of receipt of the application and supporting documentation. If the disputed service has not been provided and your provider or the Department certifies there is an “imminent and serious threat to health”, including serious pain, potential loss of life, limb, or major bodily function, immediate and serious deterioration of your health, or other similar serious conditions, the review organization must expedite review and render a decision within 3 days. These deadlines may be extended by Insurance Commissioner for good cause.
The Insurance Commissioner must adopt the IMR organization’s decision, and promptly issue a written decision.
Are Medicare Beneficiaries Entitled to IMR?: Medicare beneficiaries enrolled in Medicare + Choice products are expressly entitled to participate in the IMR process, unless or until federal law expressly preempts their participation.