If the plan says No at Level 1, what happens next?
If we say no to part or all of your Level 1 Appeal, we will send you a letter. This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal.
- If your problem is about a Medicare service or item, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 Appeal is complete.
- If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. The letter will tell you how to do this. Information is also below.
What is a Level 2 Appeal?
A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan.
My problem is about a Medi-Cal service or item. How can I make a Level 2 Appeal?
There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing.
1) Independent Medical Review
You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). An IMR is available for any Medi-Cal covered service or item that is medical in nature. An IMR is a review of your case by doctors who are not part of our plan. If the IMR is decided in your favor, we must give you the service or item you requested. You pay no costs for an IMR.
You can apply for an IMR if our plan:
- Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary.
- Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition.
- Will not pay for emergency or urgent Medi-Cal services that you already received.
- Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal.
You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue.
In most cases, you must file an appeal with us before requesting an IMR. If you disagree with our decision, you can ask the DMHC Help Center for an IMR.
- If your treatment was denied because it was experimental or investigational, you do not have to take part in our appeal process before you apply for an IMR.
- If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHC’s attention. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases.
You must apply for an IMR within 6 months after we send you a written decision about your appeal. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time.
To ask for an IMR:
- Fill out the Independent Medical Review/Complaint Form available at https://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForms.aspx. By clicking on this link, you will be leaving the IEHP DualChoice website. Or call the DMHC Help Center at 1-888-466-2219. TDD users should call 1-877-688-9891.
- If you have them, attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.
- Fill out the Authorized Assistant Form if someone is helping you with your IMR. You can get the form by clicking on Authorized Assistant Form at https://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForms.aspx. By clicking on this link, you will be leaving the IEHP DualChoice website. You complete Part A and the person you want to give permission to assist you with the Interdependent Medical Review will complete Part B. If you cannot complete the Authorized Assistant form, the person with legal authority to act for you will only need to complete Part B and attach a copy of the power of attorney for health care decisions or other documents that say that this person can make decision for you.
- Mail or fax your forms and any attachments to:
Help Center
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
FAX: 916-255-5241
If you qualify for an IMR, the DMHC will review your case and send you a letter within 7 calendar days telling you that you qualify for an IMR. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. You should receive the IMR decision within 45 calendar days of the submission of the completed application.
If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. You should receive the IMR decision within 7 calendar days of the submission of the completed application.
If you are not satisfied with the result of the IMR, you can still ask for a State Hearing.
If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process.
2) State Hearing
You can ask for a State Hearing for Medi-Cal covered services and items. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing.
In most cases you have 120 days to ask for a State Hearing after the “Your Hearing Rights” notice is mailed to you.
NOTE: If you ask for a State Hearing because we told you that a service you currently get will be changed or stopped, you have fewer days to submit your request if you want to keep getting that service while your State Hearing is pending. Read “Will my benefits continue during Level 2 appeals” in Chapter 9 of the Member Handbook, updated 09/16/22 for more information.
There are two ways to ask for a State Hearing:
- You may complete the "Request for State Hearing" on the back of the notice of action. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. Then you may submit your request one of these ways:
- To the county welfare department at the address shown on the notice.
- To the California Department of Social Services:
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430
- To the State Hearings Division at fax number 916-651-5210 or 916-651-2789.
- You can call the California Department of Social Services at 1-800-952-5253. TDD users should call 1-800-952-8349. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy.
Will my benefits continue during Level 2 appeals?
If your problem is about a service or item covered by Medicare, your benefits for that service or item will not continue during the Level 2 appeals process with the Independent Review Entity.
If your problem is about a service or item covered by Medi-Cal and you ask for a State Fair Hearing, your Medi-Cal benefits for that service or item will continue until a hearing decision is made. You must ask for a hearing on or before the later of the following in order to continue your benefits:
- Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or
- The intended effective date of the action.
If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made.
How will I find out about the decision?
If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision.
- If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision.
- If the State Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. We may stop any aid paid pending you are receiving.
If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision.
- If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment.
- If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. You can still get a State Hearing.
If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision.
- If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IRE’s decision.
- If the Independent Review Entity says No to part or all of what you asked for, it means they agree with the Level 1 decision. This is called “upholding the decision.” It is also called “turning down your appeal.”
If the decision is No for all or part of what I asked for, can I make another appeal?
If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you receive the decision. You may also ask for judicial review of a State Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you receive the decision.
If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing.
If your Level 2 Appeal went to the Medicare Independent Review Entity, you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. The letter you get from the IRE will explain additional appeal rights you may have.
Payment Problems
We do not allow our network providers to bill you for covered services and items. This is true even if we pay the provider less than the provider charges for a covered service or item. You are never required to pay the balance of any bill. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. If you get a bill that is more than your copay for covered services and items, send the bill to us. You should not pay the bill yourself. We will contact the provider directly and take care of the problem.
How do I ask the plan to pay me back for the plan’s share of medical services or items I paid for?
Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items.
If you are asking to be paid back, you are asking for a coverage decision. We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage.
- If the service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item within 5 business days from the time we receive the necessary information to make a determination and no later than 14 calendar days after we get your request.
Or, if you haven’t paid for the service or item yet, we will send the payment directly to the provider. When we send the payment, it’s the same as saying Yes to your request for a coverage decision.
- If the service or item is not covered, or you did not follow all the rules, we will send you a letter telling you we will not pay for the service or item and explaining why.
What if the plan says they will not pay?
If you do not agree with our decision, you can make an appeal. Follow the appeals process. When you are following these instructions, please note:
- If you make an appeal for reimbursement, we must give you our answer within 30 days after we get your appeal.
- If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal.
If we answer “no” to your appeal and the service or item is usually covered by Medicare, we will automatically send your case to the Independent Review Entity. We will notify you by letter if this happens.
- If the IRE reverses our decision and says we should pay you, we must send the payment to you or to the provider within 30 calendar days. If the answer to your appeal is Yes at any stage of the appeals process after Level 2, we must send the payment you asked for to you or to the provider within 60 calendar days.
- If the IRE says No to your appeal, it means they agree with our decision not to approve your request. (This is called “upholding the decision.” It is also called “turning down your appeal.”) The letter you get will explain additional appeal rights you may have. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount.
If we answer “no” to your appeal and the service or item is usually covered by Medi-Cal, you can file a Level 2 Appeal yourself (see above).
IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal.
Information on this page is current as of October 01, 2023.
H8894_DSNP_24_4164896_M Accepted