My health plan denied my doctor’s request for a surgery, medical procedure, or testing.
First, you must complain to your health plan. You can call your health plan’s customer service line and request to file a grievance. They should give you a confirmation number. If the plan does not respond to your grievance within 30 days or denies your grievance, you can elevate your appeal to the Department of Managed Health Care (DMHC).
If your plan is regulated by the DMHC, you can file a request for an Independent Medical Review (IMR). An IMR is an independent review of your medical records and your doctor’s request to determine if your plan should cover the service. DMHC processes most IMRs within 30 days.
If you are on Medi-Cal, you might consider filing an appeal to the state fair hearing office.
Review of decisions under your health plan can be very complicated. You should contact the LSNC Health Program so you can talk to a LSNC advocate for an individualized assessment of your case.