You must submit a request for an independent medical review within six months of receiving the last determination letter from your insurer. This deadline may be shorter if you are insured through your employer and the plan is “self-insured.” You should check with your employer for more information.

You must determine where to file your independent medical review. This determination depends on what type of plan you have.

HMOs, PPOs, and Specialized Plans. The California Department of Managed Healthcare (“DMHC”) regulates all health maintenance organizations (HMOs), some preferred provider organization (PPO) plans, as well as specialized plans that cover only certain kinds of care, such as certain dental and vision care plans, behavioral or mental health plans, and chiropractic plans.[6] If you need help figuring out if DMHC regulates your plan, you should visit www.hmohelp.ca.gov or call DMHC at 1-888-466-2219.

If your plan is regulated by the DMHC, you should submit a request for an independent medical review here. You should include any new information and documentation with your application. You can also print a copy of the application and fax it to (916) 255-5241 or mail it to:

Help Center
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814-2725[7]

Fee-for-service plans and PPOs. The California Department of Insurance (“CDI”) regulates indemnity health insurance plans, also known as fee-for-service plans, and most PPO plans.[8] You can call the CDI at 1-800-927-4357 to find out whether it regulates your specific plan.

If your plan is regulated by the CDI, you should apply for an independent medical review here. You should include any new information and documentation with your application. You can also print a copy of the application and fax it to (213) 897-9641 or mail it to:

Department of Insurance, Health Claims Bureau
300 S. Spring Street, South Tower
Los Angeles, CA 90013

Self-funded plans. If you receive your health insurance through your employer, check with your employer to see if your plan is “self-funded.” Neither DMHC nor CDI regulate these types of plans. If your plan is a self-funded employer plan, ask your employer to provide you with the contact information for the plan’s administrator to find out what your independent review options are.

Expedited independent medical review requests. If you seek an expedited independent medical review, ask your health care provider to certify, in writing, that a delay in receiving the requested treatment or service would create a serious and imminent risk to your health.[9]

Insurer’s responsibility. If your request for an independent medical review is granted, your health insurer has 24 hours to provide the necessary documentation and information to the independent medical reviewer.[10]