You and your HMO may disagree about the care you need. Your HMO may say that the treatment you've asked for is not necessary for your health or is experimental. Or you may have gotten emergency care that your HMO won't pay for.

HEALTH CARE INSURANCE GUIDE Useful Terms HMO Assistance COBRA Getting Insurance On Your Own MediCal HMO Medicare HMOs Disabilities Routine Care Care For Children Mental Health Emergency Care Hospital Care End Of Life Care If You Have A Complaint Request Independent Medical Review

If these things happen, you can ask for an Independent Medical Review, or IMR. The State of California hires an independent organization to conduct these reviews. This organization has doctors who review the cases. The doctors are experts on your condition, but they are not part of your HMO. And they do not get money from your HMO.

You Can Request a Review

If you had emergency or urgent care and your HMO won't pay for it. Or,
If you requested a service and your HMO says it's not medically necessary. Or,
If you asked for experimental or investigative treatment for a serious condition and your HMO won't pay for it.

To Request an Independent Medical Review (IMR)

Call HMO Help Center. The staff will help you with the review process. If your problem does not qualify for an IMR, they will tell you what else you can do. In some cases you must file a written complaint with your HMO first.
If your problem is urgent, HMO Help Center will help you request a faster review.
Your IMR must usually be decided within 30 days-or sooner if your problem is urgent. You do not attend the review.
You must ask for a review within 6 months after your HMO denies your request.
Medicare has its own review process. Call HICAP.

The California Patient's Guide provides step-by-step instructions to navigate the Inpedendent Medical Review process.

For copies of the guide, visit: www.calpatientguide.org, call: (310) 392-0522, send an email to: calpatientguide@consumerwatchdog.org, or mail a request to:
Foundation for Taxpayer and Consumer Rights
Attn: Patient Guide
1750 Ocean Park Blvd., Suite 200
Santa Monica, CA 90405

Each Independent Medical Review decision is based on the person's situation. Your name and medical records are not made public. You can read summaries of all IMR decisions. Visit www.hmophelp.ca.gov.

If You're Still Not Satisfied
You may be able to take further action. You have the right to sue if you've suffered serious bodily harm. HMO members usually resolve their cases through a process called binding arbitration. This process settles cases out of court. Before you take any action, talk to a lawyer. Visit www.calpatientguide.org.

California Patient's Guide
A guide to health care rights www.calpatientguide.org

HICAP (Health Insurance Counseling & Advocacy Program)
Information, counseling and advocacy for Medicare members
(800) 434-0222

HMO Help Center
Information and assistance for California HMO members
(888) HMO-2219 www.hmohelp.ca.gov

Medi-Cal Fair Hearing
File an appeal if your HMO denies you the services you need
(800) 952-5253