California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.74.30 - Independent Medical Review System

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Plan enrollees may request independent
				  medical review pursuant to this regulation for decisions that are eligible for
				  independent medical review under Article 5.55 and section
				  1370.4 of the Act. The independent
				  medical review process shall resolve decisions that deny, modify, or delay
				  health care services, that deny reimbursement for urgent or emergency services
				  or that involve experimental or investigational therapies. Specialized plans
				  shall provide for independent medical reviews under this section if a covered
				  service relates to the practice of medicine or is provided pursuant to a
				  contract with a health plan providing medical, surgical and hospital services.
				  The Department shall be the final arbiter when there is a question as to
				  whether a dispute over a health care service is eligible for independent
				  medical review, and whether extraordinary and compelling circumstances exist
				  that waive the requirement that the enrollee first participate in the plan's
				  grievance system.
(b) An enrollee
				  may apply for an independent medical review under the conditions specified in
				  Section 1374.30(j) of the
				  Act. The Department may waive the requirement that the enrollee participate in
				  the plan's grievance process if the Department determines that extraordinary
				  and compelling circumstances exist, which include, but are not limited to,
				  serious pain, the potential loss of life, limb or major bodily function, or the
				  immediate, and serious deterioration of the health of the enrollee.
(c) In cases involving a claim for out of
				  plan emergency or urgent services that a provider determined were medically
				  necessary, the independent medical review shall determine whether the services
				  were emergency or urgent services necessary to screen and stabilize the
				  enrollee's condition. For purposes of this section "emergency services" are
				  services for emergency medical conditions as defined in section
				  1300.71.4 of title 28, and "urgent
				  services" are all services, except emergency services, where the enrollee has
				  obtained the services without prior authorization from the plan, or from a
				  contracting provider.
(d)
				  Applications for independent medical review shall be submitted on a one-page
				  form entitled Independent Medical Review Application (DMHC IMR 11/00), which is
				  incorporated by reference, and shall be provided by the Department. The form
				  shall contain a signed release from the enrollee, or a person authorized
				  pursuant to law to act on behalf of the enrollee, authorizing release of
				  medical and treatment information. Additionally, the enrollee may provide any
				  relevant material or documentation with the application including, but not
				  limited to:
(1) A copy of the adverse
				  determination by the plan or contracting provider notifying the enrollee that
				  the request for health care services was denied, delayed or modified, in whole
				  or in part, based on the determination that the service was not medically
				  necessary;
(2) Medical records,
				  statements from the enrollee's provider or other documents establishing that
				  the dispute is eligible for review;
(3) A copy of the grievance requesting the
				  health care service or benefit filed with the plan or any entity with delegated
				  authority to resolve grievances, and the response to the grievance, if
				  any;
(4) If expedited review is
				  requested for a decision eligible for independent medical review pursuant to
				  Article 5.55 of the Act, the application shall include, a certification from
				  the enrollee's physician or provider indicating that an imminent and serious
				  threat to the health of the enrollee exists. If expedited review is requested
				  for a decision eligible for independent medical review pursuant to section
				  1370.4 of the Act, the application
				  shall include a certification from the enrollee's physician that the proposed
				  therapy would be significantly less effective if not promptly
				  initiated.