The California Patient's Guide
  Your Health Care Rights and Remedies
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Appendix B
Vital Steps to Receiving the Health Care You Need-A Checklist
  1. Find out the reason that your health care plan is refusing to provide payment for a certain health care service or treatment. Get a copy of the denial letter and a copy of your current health plan booklet that contains a summary of your benefits and procedures to follow for payment.

    Is your health plan refusing to authorize a referral to a specialist? Remember that your health plan is required to make a decision as to whether to authorize a referral to a specialist within 3 business days of when the request is made by you or your doctor and all necessary paperwork has been submitted to the plan.

    Is the denial for a procedure that has already been performed and you are receiving bills from the health care provider that your plan has not paid? First, make sure that your doctor or the health care facility where you received treatment submitted any necessary paperwork to your health care plan. Call the doctor or service provider to get copies of any paperwork submitted. In this case, there could be a misunderstanding as to whether the doctor or facility where you received health care services is outside of the network of providers that your plan will provide full payment for. Or, perhaps your plan requires you to obtain authorization in advance for certain procedures. Did you or your doctor get the necessary authorization in advance from your health plan?

    Is the service or treatment considered a "covered benefit?" Check your health plan's "Evidence of Coverage" information that should be included in a document you received when you enrolled in the plan. Call your plan administrator to obtain a current copy if you don't have one.

    Is the care you need medically necessary? If so, you may have a right to have a denial of care by your health plan reviewed independently by an outside medical review organization approved by the Department of Managed Health Care. (See section VII of this Guide).

    Is the treatment you are seeking considered experimental or investigational? If so, there is a separate independent, external review process that you should follow. (See section VII of this Guide)

  2. Find out who the appropriate contact person is at your health care plan and at your doctor's office or other treatment facility who handles questions regarding payment for health care services received. If your health care coverage is through your employer or your spouse's employer, find out who the benefits manager is and talk to that person about how to get the denial of care by the health plan resolved.

  3. If, after speaking with your doctor and the appropriate contacts with your health care plan and/or employer you still are unable to receive a satisfactory resolution, file a grievance with your health care plan and/or the Department of Managed Care.

    Your health plan must resolve your grievance within 30 days, in most cases.
    If you receive no resolution of a grievance filed with your health plan after 30 days, you may file a grievance with the Department of Managed Health Care. The Department should provide you with its decision within 30 days, unless it determines more time is needed.
    If there is a serious threat to your health if you do not receive treatment immediately, then you can submit a grievance directly to the Department of Managed Care without first having to go through your health plan's grievance procedure. (See section VI of this guide)

  4. If your plan's denial of care was based on a decision that the particular treatment was not "medically necessary," and you do not receive a satisfactory resolution through your health plan's internal grievance process, ask for an independent review of your plan's decision.

    If you meet all the criteria as more fully outlined in section xx of this guide, you may be eligible to submit your dispute to an independent medical review process that is available through the Department of Managed Health Care. This decision as to whether your dispute is eligible for the independent review process is made by the Department of Managed Health Care.

  5. If, after using the independent review process, you are still unable to obtain a satisfactory resolution, you may be able to file a lawsuit in state court to hold your health care plan responsible for its denials of care that resulted in harm to you.

    If your plan's decision to deny you care is based on a reason other than that the care was not medically necessary, then you may be able to file a lawsuit immediately without first having to go through the grievance process. (See Chapter VII of this guide for more information on California's "right to sue" law.)