Independent Medical Review

review

 

Members may request an independent medical review (“IMR”) of a disputed health care service from the Health and Human Services Commission (HHSC) if he/she believes that health care services have been improperly denied, modified, or delayed by Molina Healthcare or one of its contracted providers. A “disputed health care service” is any health care service eligible for coverage and payment that has been denied, modified or delayed by Molina Healthcare or one of its contracted providers, in whole or in part because the service is not medically necessary.

 

The IMR process is in addition to any other procedures or remedies that may be available to members. The IMR process is not available if the member has already filed for a State Fair Hearing. Members pay no application or processing fees of any kind for IMR.  He/She has the right to give information in support of the request for an IMR. Molina Healthcare will give the member an IMR application form with any disposition letter that denies, modifies or delays healthcare services. A decision not to take part in the IMR process may cause the member to lose any statutory right to take legal action against Molina Healthcare regarding the disputed health care service.
 

Eligibility: The member’s application for an IMR will be reviewed by the HHSC to confirm that:

 
  1. Members have one of the following:
    1. The provider has recommended a health care service as medically necessary.
    2. The member has received urgent care or emergency services that a provider determined was medically necessary.
    3. The member has been seen by a plan provider for the diagnosis or treatment of the medical condition for which they seek medical review.
  2. The disputed health care service has been denied, modified or delayed by Molina Healthcare or one of its contracting providers, based in whole or in part on a decision that the health care service is not medically necessary: and
  3. The member has filed a complaint with Molina Healthcare or its contracting provider and the disputed decision is upheld or the complaint remains unresolved after thirty (30) days. The member is not required to wait for a response from Molina Healthcare for more than thirty (30) days.

 

If the member’s complaint requires Expedited Review they may bring it immediately to the HHSC’s attention. They are not required to wait for response from Molina Healthcare for more than three (3) days. The HHSC may waive the requirement that the member follows Molina Healthcare’s complaint process in extraordinary and compelling cases.

If the case is eligible for IMR, the dispute will be submitted to a medical specialist who will make an independent determination of whether or not the care is medically necessary. The member will get a copy of the assessment made in the case. If the IMR determines the service is medically necessary, Molina Healthcare will provide the health care service.

For non-urgent cases, the IMR organization designated by the DMHC must provide its determination within thirty (30) days of receipt of the member’s application and supporting documents. For urgent cases involving an imminent and serious threat to the member’s health, including but not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of their health, the IMR organization must provide its determination within three (3) days.

For more information regarding the IMR process, or to request an application form, please call Molina Healthcare toll-free at (866) 449-6849.. Members who are deaf or hard of hearing, can call our dedicated TTY line toll-free TTY (English) (800) 735-2989, (Spanish) (800) 662-4954.