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INFORMATION AND INSTRUCTIONS REGARDING YOUR APPLICATION FOR INDEPENDENT MEDICAL REVIEW

Before you request an Independent Medical Review with the California Department of Insurance, you are required to first file an appeal/grievance with the insurance company in an effort to resolve the issue(s). If you do not receive a satisfactory response after 30 days, then complete the Application for Independent Medical Review, attach copies of any important papers that relate to your complaint and mail to California Department of Insurance at the address shown on the application form. You may also attach additional sheets as necessary to explain and/or describe the situation and disagreement with your insurance company. We consider this information necessary to our review and within the powers and duties expressed in the California Insurance Code, Section 12921.3 and Section 10169. Please review our privacy statement regarding information we obtain from you.

You have the right to provide any information or documentation you believe will support your position in this review.

You may inspect the information you submit at any time as long as the department’s case is maintained. All original documents will be returned to you upon completion of our handling.

APPLICATION FOR INDEPENDENT MEDICAL REVIEW MAY BE SUBMITTED TO THE DEPARTMENT OF INSURANCE FOR THE FOLLOWING TYPES OF PROBLEMS:

1. Denial of a claim due to the company’s opinion that the treatment or service is not medically necessary or that it is experimental and excluded by a policy provision.
2. An offer of an amount less than that indicated in the policy due to the company’s opinion of medical necessity.
3. Delay in settlement of a claim due to the disputed issue of medical necessity.
4. Denial of a claim for urgent or emergency services

Under the Independent Medical Review process, one or more physicians will determine these issues and their decision will be binding on the insurance company.

Please be aware that a copy of this Application for Independent Medical Review will be provided to the insurance company. Also, please be advised that:

• A decision not to participate in the independent review process may cause the forfeiture of any statutory right to pursue legal action against the insurer regarding the disputed health care service.
• Your consent to obtain any necessary medical records from the insurer, any of its contracting providers, and any out-of-plan provider the insured may have consulted on the matter, is necessary to be signed by you.
• You have the right to provide information or documentation, either directly or through your provider, regarding any of the following:
• The provider's recommendation indicating that the disputed health care service is medically necessary for the insured's medical condition.
• Medical information or justification that a disputed health care service, on an urgent care or emergency basis, was medically necessary for the insured's medical condition.
• Reasonable information supporting your position that the disputed health care service is or was medically necessary for the medical condition, including all information provided to the insured by the insurer or any of its contracting providers, still in the prossession of the insured, concerning an insurer or provider decision regarding disputed health care services, and a copy of any materials the insured submitted to the insurer, still in the possession of the insured, in support of the grievance, as well as any additional material that the insured believes is relevant.