What Was Measured?
How often is a health plan’s denial of a medical service decided in favor of the plan member who requested the review?
If your health plan denies your request for medical services or treatment, you can file a complaint (grievance) with your plan. If you disagree with your plan's decision, you can ask California’s Department of Managed Health Care (DMHC) for an Independent Medical Review (IMR).
A higher rate (longer bar) means that the health plan was wrong more often, compared to other plans, in its decisions to refuse coverage for a member’s treatment or care. See the About the HMO Ratings page for details about how the IMR rate is calculated.
These results are based on records kept by the Department of Managed Health Care.
Why Is It Important?
The Independent Medical Review (IMR) cases decided in favor of the plan member is one measure of whether HMOs make medically correct decisions. Though these corrections involve only a small number of members, it is troubling when a member has to use the IMR process to get the care they need. HMO members should be aware that they can request an IMR.
Compare California Scores to National Results
No nationwide results are available for this measure.
What Was the Source?
The data sources for this average rate came from DMHC’s 2009 and 2010 Independent Medical Review and Complaint Results report.