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96 • Coverage/Benefits Disputes • Appeals of Denials, delays, reductions, suspensions, terminations of Care • Appeals of failure to approve, furnish, provide Payment • Quality of Care • Billing and Financial • Attitude and Service

These issues handled through the statewide review system are consistent with the issues that would otherwise be addressed by 42 CFR 457.1130(b).

DMHC reviews the appeals as a standard review or as an Independent Medical Review (IMR). (The IMR allows subscribers to obtain an impartial review of any health care service eligible for coverage and payment under a health plan contract that has been denied, modified, or delayed by a decision of the plan, or by one of its contracting providers, in whole or in part due to a finding that the services are not medically necessary). The standard review and IMR process include a final resolution by DMHC staff or DMHC contractor that is binding on the health plan.

As required by 42 CFR 457.1160(b), California has established a time frame for completing external reviews, through both the standard review process and IMR, that accounts for the medical need of patients. To this end, within standard conditions, the review is completed within 90 calendar days of the date that a request for review was made. California also provides review within 72 hours for situations if operating under the standard timeframe could jeopardize the life or health of the enrollee.

The patient protection provision in state law that was established for managed care enrollees in California also apply to the Program subscribers since they are enrolled in licensed managed care plans. Thus, members are instructed to use their health plan’s grievance process-including the DMHC’s IMR process, if the subscriber has a grievance. When subscribers call DHCS directly, staff serves as an ombudsman assisting subscribers with the grievance process.

b. As required by 42 CFR 457.1180, California provides or requires the managed care plans to provide timely written notice of any decision that is subject to review under 457.1130(b) (described above). This notice includes the reason for the determination, the standard and expedited timeframes (described above), the way in which review can be requested, and the circumstances in which the enrollee may continue pending review.

c. As required by 42 CFR 457.1140(d), all applicants and enrollees have the opportunity to represent themselves, or have a representative they choose in the review process. All applicants and enrollees can review their files, or other information that is relevant to their review decision in a timely manner. And, all applicants and enrollees have the