What Was Measured?
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 the state’s Department of Managed Health Care (DMHC) for an Independent Medical Review (IMR).
This table shows how often a plan’s denial of service was overturned by the Independent Medical Review organization. This rate was determined by dividing the plan’s total number of overturned denials by the total number of HMO members within DMHC’s jurisdiction over a three year period (2004-2006). More information on this table is found on the About the HMO Ratings page.
Why Is It Important?
The average rate of a plan’s overturned service denials is one measure of whether HMOs make medically correct decisions. While the number of overturned IMRs is small compared to the number of managed care members in California, it is disturbing when a member believes they are entitled to necessary health care services but has to use the IMR process to get the care they need. HMO members should be aware that they can request an IMR.
What Was the Source?
The data sources for this average rate came from the 2004, 2005, and 2006 DMHC Annual Reports. To view these reports, go to the Departmental Reports page of the DMHC website.