Return
to Hip Universe “You Are Here”
(California)
What
to do in a dispute with an HMO in light of Monday's ruling (June 21, 2004—the
case is Aetna Health Inc. vs. Davila, 02-1845):
--
You must first file a complaint with your health plan before lodging a formal grievance
with the Department of Managed Health Care, the California agency that licenses
and regulates HMOs. Contact your health plan to get information regarding its
complaint process.
--
If your health plan does not resolve the issue to your satisfaction within 30
days, you can file a complaint with the Department of Managed Health Care. The
department's complaint process consists of a review of all written information
provided by both you and the health plan, including relevant medical records,
if necessary.
--
For grievances of treatment or reimbursement denials based on medical
decisions, you may pursue an independent medical review through the department.
You must submit a request for a review to the department within six months of
receiving the denial from the HMO.
--
If you still cannot resolve the dispute, you may opt to go through binding
arbitration if it is a requirement or option of your health plan.
--
For additional information, call your health plan directly or contact the
Department of Managed Care's Help Center at (888) 466-2219 or at www.hmohelp.ca.gov .
Source:
Department of Managed Health Care; San Francisco Chronicle research