IMR Application/Complaint Form Instruction Sheet
If you have questions, call the Department at 1-888-466-2219 or TDD at 1-877-688-9891. This call is
free.
Before You File:
In most cases, you must go through your health plan’s complaint or grievance process before you
file a complaint or IMR request with the Department. Your health plan must give you a decision
within 30 days or within 3 days if your problem is an immediate and serious threat to your health.
If your health plan denied your treatment because it was experimental/investigational, you do not
have to take part in your health plan’s complaint or grievance process before you file an IMR
application.
You must apply for an IMR within six months after your health plan sends you a written response to
your appeal. You can still file your application after six months if there were special circumstances
that kept you from filing timely. Please be aware that if you decide not to file a complaint with the
Department for an issue that would qualify for an IMR, you may be giving up your rights to pursue
legal action against your plan regarding the service or treatment you are requesting.
How to File:
1
. File online at www.HealthHelp.ca.gov. [This is the fastest way.]
OR
Fill out and sign the IMR Application/Complaint Form.
2
3
. If you want someone to help you with your IMR or complaint, complete the ‘Authorized
Assistant Form.’ Both you and your authorized assistant must sign the form.
. If you have medical records from out of network providers, please include them with your
IMR Application/Complaint Form. Your plan will provide medical records from network
providers.
4
5
. You may include other documents that support your request. However, there is no need to
provide any documents or letters between you and your plan relating to this complaint. The
Department will obtain this information directly from your plan as part of the investigation.
. If you are not submitting online, please mail or fax your form and any supporting documents
to:
Department of Managed Health Care Help Center
9
80 9th Street, Suite 500
Sacramento, CA 95814-2725
FAX: 916-255-5241
What Happens Next?
The Department will determine if your case qualifies as an IMR or a complaint. Cases qualify for an
IMR if health care services were delayed, modified or denied based on a medical necessity or as
experimental/investigational.
Cases that do not qualify for an IMR are processed through the consumer complaint process. These
cases involve issues such denials of health care service as not a covered benefit, claim payment
disputes, cancellation of coverage, quality of care, and deductible/out of pocket expenses.
The Department will send you a letter within seven days telling you if you qualify for an IMR. If ithe
Department decides that your complaint qualifies for an IMR, your case is assigned to a state
contractor who will perform the review. The state contractor is also called the Independent Medical
Review Organization (). All of the information the Help Center hasrelated to your complaint, including
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