Rate of Cases Decided in Favor of HMO Member – Independent Medical Reviews (IMR)

HMO members should be aware that they can file an appeal when their health plan denies medical care. One type of external appeal is called an Independent Medical Review (IMR) when it is filed with the Department of Managed Health Care (DMHC).

What do the stars mean?

How often is a health plan’s denial of a medical service decided in favor of the plan member who requested the review?

If your health plan denies your request for medical services or treatment, you can file a complaint (grievance) with your plan. If you disagree with your plan's decision, you can appeal their decision and ask the DMHC for an IMR.

In the chart, a longer bar means the health plan had a higher rate at being wrong, compared to other plans, in decisions to refuse to cover a member’s treatment or care.

Why is This Important?

The Independent Medical Review (IMR) cases decided in favor of the plan member is one measure of whether HMOs make medically correct decisions. Though these corrections involve only a relatively small number of members, it is important that all members know that they have this right to appeal health care decisions.

What Is the Source?

The data sources for this average rate came from DMHC’s 2012 and 2013 Independent Medical Review by Health Plan Results Report. For further information about the data on this page, please go to About the HMO Independent Medical Review and Complaint Ratings.

This table shows how often a plan’s denial of service was resolved in favor of the plan member requesting the review.

Per 100,000 HMO Members
  • 0.00 (Better)
  • (Worse) 20.00
Aetna Health of California, Inc. - HMO 13.0 Horizontal bar, 65 units
Anthem Blue Cross - HMO * 17.0 Horizontal bar, 85 units
Blue Shield of California - HMO * 18.0 Horizontal bar, 90 units
CIGNA - HMO 11.0 Horizontal bar, 55 units
Health Net of California, Inc. - HMO 10.0 Horizontal bar, 50 units
Kaiser Permanente (Northern and Southern California) 5.0 Horizontal bar, 25 units
UnitedHealthcare of California - HMO 11.0 Horizontal bar, 55 units
Western Health Advantage - HMO 17.0 Horizontal bar, 85 units
Sharp Health Plan - HMO 15.0 Horizontal bar, 75 units
*Rates for Anthem Blue Cross and Blue Shield include aggregated data for both their HMO and PPO health plan products that are regulated by the Department of Managed Health Care.

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