Thursday, December 18, 2025
DMHC fines UnitedHealthcare Benefits Plan of California $475,000 for delaying medical care and payments
SACRAMENTO - The Department of Managed Health Care (DMHC) fined UnitedHealthcare Benefits Plan of California $475,000 for failing to timely implement Independent Medical Review (IMR) decisions, which delayed medical care. In addition, the plan’s failure to carry out timely IMR decisions led to delays in providers being paid.
“Health plans must provide members with the medical care they need without delays,” said DMHC Director Mary Watanabe. “The health plan violated the law when it failed to timely implement the determinations made by the independent reviews, which overturned the plan’s previous denials.”
INDEPENDENT MEDICAL REVIEWS: Californians enrolled in health plans regulated by the DMHC have the right to appeal their health plan's decision by applying for an IMR if their plan denies, changes, or delays their request for medical services, including experimental or investigational services and payment for emergency treatment. During an IMR, doctors and providers who are independent and not affiliated with the health plan review the case to see if the health plan appropriately denied the requested services, or if the member should receive the requested medical service or treatment. If an IMR determines the requested medical service or treatment is medically necessary, the plan must authorize the service or treatment. California law requires health plans to authorize the services within five working days of receiving an IMR determination.
BACKGROUND: Following health plan member complaints to the DMHC’s Help Center, the Department found four separate cases in which the plan failed to implement IMR decisions within five working days in violation of the law. One case involved the plan’s failure to timely authorize a health plan member’s treatment for mental health after the IMR determined the requested care to be medically necessary. In the second case, the plan failed to timely issue payment on an out-of-network provider’s claim for a sleep apnea device after the IMR determined the device to be medically necessary for the member. The remaining cases involved treatments for glioblastoma and lung cancer, which the plan denied as experimental or investigational. In both cases, IMRs determined the treatments were medically necessary, and the plan failed to timely issue payments to providers after the IMR determinations. Additionally, in three of the four cases, the plan either delayed in acknowledging or responding to member grievances or provided an unclear claim denial or grievance response.
In addition to paying the fine, the plan will provide the Department with updated procedures involving IMRs, including authorizing or issuing payment for services within five working days of receiving an IMR determination. The plan will also update procedures involving grievances, including the timeframes to acknowledge and resolve grievances and the information required to be included in grievance resolution letters.
WHAT MEMBERS NEED TO KNOW: The DMHC encourages health plan members experiencing issues with their health plan, including denials, delays or modifications of requested health care services, to file a complaint, also called an appeal or grievance, with their health plan. If the member does not agree with their health plan's response or the plan takes more than 30 days to respond to the grievance, the member can contact the DMHC Help Center. If a health plan member is experiencing an urgent issue, they can contact the DMHC Help Center immediately. Health plan members can file a complaint or apply for an Independent Medical Review with the DMHC Help Center at www.DMHC.ca.gov or by calling 1-888-466-2219.
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About DMHC
The mission of the DMHC is to ensure health plan members have access to equitable, high-quality, timely, and affordable health care within a stable health care delivery system. The DMHC accomplishes this important mission by regulating health plans, enforcing California’s strong consumer protection laws and assisting health plan members. For more information visit www.DMHC.ca.gov.