Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California

What Is Form DMHC20-224?

This is a legal form that was released by the California Department of Managed Health Care - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the California Department of Managed Health Care;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DMHC20-224 by clicking the link below or browse more documents and templates provided by the California Department of Managed Health Care.

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Download Form DMHC20-224 "Independent Medical Review (Imr) Application/Complaint Form" - California

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State of California - Health and Human Services Agency
Department of Managed Health Care
IMR APPLICATION/COMPLAINT FORM - English
DMHC 20-224
New: 11/15
Rev: 01/20
I
M
R
(IMR) A
/C
F
NDEPENDENT
EDICAL
EVIEW
PPLICATION
OMPLAINT
ORM
IMPORTANT INFORMATION
You can submit your IMR Application/Complaint Form online at: www.HealthHelp.ca.gov
FREE: The IMR/Complaint process is free.
 FAST: IMRs are usually decided within 45 days, or within 7 days if the health issue is urgent.
 SUCCESSFUL: Approximately 60 percent of patients receive the requested service through IMR.
 FINAL: Health plans must follow the IMR decision and promptly provide the service.
P
I
ATIENT
NFORMATION
First Name
Middle Initial
Last Name
Gender: Male Female Other
Patient’s Date of Birth (mm/dd/yyyy)
Name of Parent or Guardian if Filing for Minor Child
Street Address
City
State
Zip
Primary Phone #
Secondary Phone #
Email Address
 Yes  No
Would you like communication/correspondence sent to this email?
Health Plan Name
Patient’s Membership #
Medical Group Name
(if enrolled in a medical group)
Employer
 Yes  No
Do you want someone to help you with your complaint?
If yes, please complete the attached ‘Authorized Assistant Form.’
 Yes  No
Do you have Medi-Cal?
 Yes  No
If yes, have you filed a Request for a State Fair Hearing?
 Yes  No
Do you have Medicare or Medicare Advantage?
Have you filed a complaint or grievance with your health plan?
 Yes  No
 Yes  No
Do you want payment for a health care service that you already received?
If yes, list the date(s) of service, and the provider’s name:
YOUR HEALTH PROBLEM
(Use a separate sheet and attach other documents, if needed.)
 Yes  No
Do you want your health plan to pay for future services?
State of California - Health and Human Services Agency
Department of Managed Health Care
IMR APPLICATION/COMPLAINT FORM - English
DMHC 20-224
New: 11/15
Rev: 01/20
I
M
R
(IMR) A
/C
F
NDEPENDENT
EDICAL
EVIEW
PPLICATION
OMPLAINT
ORM
IMPORTANT INFORMATION
You can submit your IMR Application/Complaint Form online at: www.HealthHelp.ca.gov
FREE: The IMR/Complaint process is free.
 FAST: IMRs are usually decided within 45 days, or within 7 days if the health issue is urgent.
 SUCCESSFUL: Approximately 60 percent of patients receive the requested service through IMR.
 FINAL: Health plans must follow the IMR decision and promptly provide the service.
P
I
ATIENT
NFORMATION
First Name
Middle Initial
Last Name
Gender: Male Female Other
Patient’s Date of Birth (mm/dd/yyyy)
Name of Parent or Guardian if Filing for Minor Child
Street Address
City
State
Zip
Primary Phone #
Secondary Phone #
Email Address
 Yes  No
Would you like communication/correspondence sent to this email?
Health Plan Name
Patient’s Membership #
Medical Group Name
(if enrolled in a medical group)
Employer
 Yes  No
Do you want someone to help you with your complaint?
If yes, please complete the attached ‘Authorized Assistant Form.’
 Yes  No
Do you have Medi-Cal?
 Yes  No
If yes, have you filed a Request for a State Fair Hearing?
 Yes  No
Do you have Medicare or Medicare Advantage?
Have you filed a complaint or grievance with your health plan?
 Yes  No
 Yes  No
Do you want payment for a health care service that you already received?
If yes, list the date(s) of service, and the provider’s name:
YOUR HEALTH PROBLEM
(Use a separate sheet and attach other documents, if needed.)
 Yes  No
Do you want your health plan to pay for future services?
IMR APPLICATION/COMPLAINT FORM - English
Page 2
DMHC 20-224
What is your medical condition or doctor’s diagnosis (Please be specific)
What medical treatment(s)/service(s) and/or medication(s) are you asking for? (Please be specific)
 Yes  No
Did your
health plan deny, delay or modify your treatment?
If yes, please check the reason given: (Check one)
 Not Medically Necessary
 Experimental or Investigational
 Not an Emergency/Urgent
 Not an Emergency/Urgent  Other (Please explain below)
List the name and phone number of your primary care doctor and other providers who have seen, treated, or
advised you for this condition.
 Yes
 No
Have you seen any out-of-network providers for your condition?
If yes, please include the medical records with this form.
Briefly describe the problem you are having with your plan. For example, explain if the problem is a denied
treatment, an unpaid bill, trouble getting an appointment or medication, or if your coverage has been cancelled
by the health plan.
MEDICAL RELEASE
I request the Department of Managed Health Care (Department) to make a decision about my problem with my
health plan. I request the Department to review my Independent Medical Review (IMR) Application/Complaint
Form to determine if my complaint qualifies for an IMR or the Department’s Complaint process. I allow my
providers, past and present, and my plan to release my medical records and information to review this issue.
These records may include medical, mental health, substance abuse, HIV, diagnostic imaging reports, and
other records related to my case. These records may also include non-medical records and any other
information related to my case. I allow the Department to review these records and information and send them
to my plan. My permission will end one year from the date below, except as allowed by law. For example, the
law allows the Department to continue to use my information internally. I can end my permission sooner if I
wish. All the information that I have provided on this sheet is true.
Patient or Parent Name (Print)
Patient or Parent Signature
Date
Please see the instruction sheet for mailing or faxing information.
STATISTICAL INFORMATION ONLY
You are asked to voluntarily provide the following information. Giving this information will help the Department
identify any patterns of problems. Health and Safety Code section 1374.30 authorizes the Department to
obtain this information for research and statistical purposes. Giving this information is optional and will not
affect the IMR or complaint decision in any way.
Primary Language Spoken:
 Yes
Would you like us to communicate/correspond with you in your primary language?
Race/Ethnicity:
State of California - Health and Human Services Agency
Department of Managed Health Care
AUTHORIZED ASSISTANT FORM - English
DMHC 20-160
New: 04/06
Rev: 01/20
AUTHORIZED ASSISTANT FORM
If you want to give another person permission to assist you with your Independent Medical
Review (IMR) or complaint, complete Parts A and B below.
If you are a parent or legal guardian filing this IMR or complaint for a child under the age of 18,
you do not need to complete this form.
If you are filing this IMR or complaint for a patient who cannot complete this form because the
patient is either incompetent or incapacitated, and you have legal authority to act for this
patient, please complete Part B only. Also attach a copy of the power of attorney for health
care decisions or other documents that say you can make decisions for the patient.
PART A: COMPLETED BY PATIENT
I allow the person named below in Part B to assist me in my IMR or complaint filed with the
Department of Managed Health Care (Department). I allow the Department and IMR staff to share
information about my medical condition(s) and care with the person named below. This information
may include mental health treatment, HIV treatment or testing, alcohol or drug treatment, or other
health care information.
I understand that only information related to my IMR or complaint will be shared.
My approval of this assistance is voluntary and I have the right to end it. If I want to end it, I must
do so in writing.
Patient Name (Print)
Patient Signature
Date
PART B: COMPLETED BY PERSON ASSISTING PATIENT
Name of Person Assisting (Print)
Address
City
State
Zip
Relationship to Patient
Primary Phone #
Secondary Phone #
Email Address
 My power of attorney for health care decisions or other legal document is attached.
IMR APPLICATION/COMPLAINT FORM - English
Page 1
IMR Application/Complaint Form Instruction Sheet
If you have questions, call the Help Center at 1-888-466-2219 or TDD at 1-877-688-9891. This call is
free.
Before You File:
In most cases, you must complete your plan’s complaint or grievance process before you file a
complaint or IMR request to the Department. Your plan must give you a decision within 30 days or
within 3 days if your problem is an immediate and serious threat to your health.
If your plan denied your treatment because it was experimental/investigational, you do not have to
take part in your plan’s complaint or grievance process before you file an IMR application.
You must apply for an IMR within six months after your health plan sends you a written response to
your appeal. The Department may accept your application after six months if it is determined that
circumstances prevented timely submission. Please be aware that if you decide not to file a
complaint with the DEPARTMENT for an issue that would qualify for an IMR, you may be giving up
your rights to pursue legal action against your plan regarding the service or treatment you are
requesting.
How to File:
1. File online at www.HealthHelp.ca.gov. [This is the fastest way.]
OR
Fill out and sign the IMR Application/Complaint Form.
2. If you want someone to help you with your IMR or complaint, complete the ‘Authorized
Assistant Form.’
3. If you have medical records from out of network providers, please include them with your
IMR Application/Complaint Form. Your plan will provide medical records from network
providers.
4. You may include other documents that support your request. However, there is no need to
provide any documents or correspondence between you and your plan relating to this
complaint.
The Department will obtain this information directly from your plan as part of the
investigation.
5. If you are not submitting online, please mail or fax your form and any supporting documents
to:
Department of Managed Health Care Help Center
980 9th Street, Suite 500
Sacramento, CA 95814-2725
FAX: 916-255-5241
What Happens Next?
The Help Center will send you a letter within seven days telling you if you qualify for an IMR. If it is
determined that your complaint qualifies for an IMR, your case is assigned to a state contractor who
will perform the review. The state contractor is also known as the Independent Medical Review
Organization (IMRO). All of the information in the Help Center’s possession related to your complaint,
including your medical records, will be sent to the IMRO. The IMRO will make a decision usually
within 30 days or within seven days if your case is urgent. You will be notified in writing of the
decision.
If it is determined that your complaint should be reviewed through the Consumer Complaint process,
a decision about your issue will be made within 30 days. You will be notified in writing of the decision.
IMR APPLICATION/COMPLAINT FORM - English
Page 2
IMR Application/Complaint Form Instruction Sheet
The
Information Practices Act of 1977 (California Civil Code Section 1798.17) requires the following
notice.
California’s Knox-Keene Act gives the Department the authority to regulate health plans and
investigate the complaints of health plan members.
The Department’s Help Center uses your personal information to investigate your problem with
your plan and to provide an IMR if you qualify for one.
You provide the Department this information voluntarily. You do not have to provide this
information. However, if you do not, the Department may not be able to investigate your
complaint or provide an IMR.
The Department may share your personal information, as needed, with the plan and providers
who conduct the IMR.
The Department may also share your information with other government agencies as required
or allowed by law.
You have a right to see your personal information. To do this, contact the Department Records
Request Coordinator, Department of Managed Health Care, Office of Legal Services, 980 9th
Street Suite 500, Sacramento CA 95814-2725, or call 916-322-6727.

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