Health Administration Responsibility Project
As more physicians and patients are involved in various managed care
plans, it becomes increasingly possible that a patient will be faced
with the denial of a treatment or other medical service. While such
situations are never easy, there are some resources available which
Navigating a Managed Care Denial
The Medical Board of California
from Jan. 1997 Action Report
- By Law, every health care service plan must have a procedure in
place for receiving and handling enrollee appeals and grievances.
In most cases the plan has 60 days to respond to the situation,
but in urgent situations this drops to five days.
- When a patient feels that a requested service was denied inappropriately,
the first thing he should do is read the Evidence of Coverage booklet
which plans are required to provide to each enrollee. If the patient
cannot find or never received one, they should be available from the
employer, or by calling the health plan.
- The Evidence of Coverage booklet is required to describe the steps to
take to initiate an appeal. While the appeal must come from the
patient or responsible party, the physician or his staff can assist
in preparing the appeal, by providing information concerning the
- Under Business and Professions Code sec. 2056, it is illegal for a
plan to retaliate against a physician who acts as a patient advocate
in such circumstances.
- The patient should be prepared to comply with any reasonable
requirements contained in the appeal procedure, and to provide any
information the plan requests, including record releases.
- If the health plan is unresponsive to the appeal, does not meet legal
time limits, or does not offer a resolution satisfactory to the patient,
he can request assistance from the Department of Corporations, which
regulates health care service plans. The department has a toll-free
telephone line for patients to call for help. If the problem is
within the legal jurisdiction of the department, they will send the
patient a form called Request for Assistance. It is important for
the patient to know that the Department of Corporations cannot
intervene until the patient has gone through the appeal or grievance
process set forth in the plan's Evidence of Coverage booklet.
If the life or health of the patient would be jeopardized by delay,
the department can take expedited action even if there has been no
appeal directly to the plan.
- Some plans require enrollees to submit to binding arbitration of
grievances. It is not necessary for the patient to complete that
process before filing a Request for Assistance with the Department
The Department of Corporation's toll-free patient assistance line is: 1-800-400-0815
The Dept. of Corporations no longer handles HMO complaint.
Go to the website of the Dept. of Managed Health Care