Friday, August 5, 2011


California’s Independent Medical Review Process for Denials of Care Meet Highest Federal Healthcare Reform Standards

The state is one of the 23 states and territories that meet new consumer protection standards under federal health care reform

(Sacramento) – The California Department of Managed Health Care (DMHC) has received confirmation from the federal Health and Human Services Agency (HHS) that its Independent Medical Review (IMR) process, which grants privately insured patients the right to challenge a health plan’s denial of a medical treatment, meets all of the strictest federal standards under the Patient Protection and Affordable Care Act.

“We were confident that California’s IMR process, established in 2000 as one of the first in the nation, would meet federal standards and not require any additional legislative changes,” said Edward G. Heidig, Interim Director of the Department of Managed Health Care. “California’s health plan consumers have long had the right receive an impartial, independent third-party review of a health plan’s decision to deny certain care, and now this important protection is being extended to all Americans.”

The recently published federal rules set standards for the states’ internal claims and appeals and external review processes. The rules ensures that consumers have the right to information about why a claim or coverage was denied, the right to appeal the decision to the health plan or insurer, and if the problem is not resolved through the internal appeal, the right to third-party independent review of the decision. California has been designated as a National Association of Insurance Commissioners “parallel state” for external review of health plan denials of care. 

States were given three options for meeting the federal standards. California is one of 23 states meeting the strictest standards for consumer protection based on the Uniform Health Carrier External Review Model Act written by the National Association of Insurance Commissioners. Ten states were able to show that their external review process was similar to the federal rules, and they may continue to use those standards until 2014. The remaining 18 states and five territories that have not met the standards must choose an HHS-administered process or contract with an accredited independent review organization to perform the reviews on their behalf.

Consumers who have questions about the independent review process or other health care rights may call the DMHC’s Help Center at 1-888-466-2219.

The California Department of Managed Health Care is the only stand-alone HMO watchdog agency in the nation, touching the lives of more than 21 million enrollees. The DMHC has assisted more than 800,000 Californians resolve their HMO problems through its 24-hour Help Center, educates consumers on health care rights and responsibilities, and works closely with HMO plans to ensure a solvent and stable managed health care system.