This regulation, which became effective in September 2005, provides a mechanism for health plan enrollees to challenge their plans’ denials of coverage. The regulation details how applications for Independent Medical Review should be submitted and what supporting materials may be included. It also explains that the IMR process is the exclusive forum for disputes about medical necessity, but allows plans to offer and use their own review process if the situation does not involve medical necessity.
The regulation affords the enrollee six months from receipt of the plan’s written response to the enrollee’s grievance to file the request for IMR. Applications cannot be denied due to lack of supporting documentation, and extensions will be approved if the delay was reasonable under the circumstances. Additionally, the DMHC must advise the enrollee of the most efficient means of completing an IMR application if it lacks necessary information. Additionally, this amended regulation allows Medi-Cal health plan enrollees to file for IMR as long as they have not yet presented the dispute for resolution through the Medi-Cal fair hearing process. Finally, it requires DMHC to notify the enrollee and the plan of the acceptance or rejection of the IMR application within seven calendar days of receipt (48 hours for an expedited review), and mandates that each reviewer issue a thorough written analysis of the decision in plain English. [Download]