Unfortunately, the first year s department budget leaves this outreach campaign underfunded. It remains to be seen how well the DMHC will be able to pursue the campaign. The DMHC operates an HMO Help Line to assist consumers with HMO issues. The Help Line staff includes attorneys and nurses. The Help Line currently receives 15,000 calls each month.
Assistance is available in several languages.
If a health care service plan denies, modifies, or delays a decision, in whole or in part, due to a finding that the service is not medically necessary, and the service would otherwise be covered under the plan, a consumer may ask for an independent medical review. An independent medical review is available when a medical provider has recommended a service as medically necessary, an enrollee received urgent care or emergency services that a provider determined was medically necessary, or the enrollee was seen by an in-plan provider for diagnosis or treatment of a medical condition for which the enrollee seeks independent review. The DMHC may seek to incorporate the appeal rights of Medi-Cal and Medicare beneficiaries into the independent medical review in order to avoid duplication and conflict, but the procedure must still protect beneficiaries rights. An enrollee must first file a grievance with the health care plan, but may ask for the independent medical review if the disputed decision is upheld or the grievance is not resolved in thirty days. An enrollee has six months to file for an independent medical review, although the director of the DMHC can waive the deadline if an extension is warranted.