Consumer Complaints and Appeals
You have the right to disagree with an HMO's decision to deny or limit a medical service. A description of the appeal process should be in your member handbook provided by the HMO.
If you are dissatisfied with the results of your appeal to the HMO, you can take your case further to an independent utilization review organization for a fee of $25. The fee can be reduced to $2 for members who show eligibility for government assistance programs.
To take your appeal outside of the HMO, submit an appeal form available from your HMO to the Department of Health and Senior Services within 30 business days of the denial, along with the filing fee. Your appeal form will be forwarded to an independent utilization review organization for full review. The organization will make its recommendation to the HMO. The HMO then must notify you or your doctor whether it accepts that recommendation. If it does not, it must explain the reasons for the rejection.
Consumers also have the right to file complaints about any aspect of HMO operations. HMOs are required to establish a complaint system and must respond to your complaint within 30 days. A description of the complaint process can be found in your member handbook.
These appeal and complaint rights are different for plans which are classified as "self-funded." Check with your employer or HMO to find out which process applies to you.