California Independent Medical Review Application (8 CCR 9768.10 Mandatory Form)

• Category: California Workers Compensation - Official - General
• State: California
• Control #: CA-9768-10
• Format: PDF

Description

Independent Medical Review Application (8 CCR 9768.10 Mandatory Form) The California Independent Medical Review Application (8 CCR 9768.10 Mandatory Form) is a form used to request an independent review of a health plan's denial of services or treatments to a patient. The form is required when a patient disagrees with a health plan's decision and wishes to dispute the denial. It is mandated by the California Department of Managed Health Care and is used to ensure that all health plans are held accountable for their decisions. The form is divided into three sections for the patient, the attending provider, and the health plan. The patient section requires the patient's contact information, the reason for the dispute, and the requested resolution. The attending provider section requires the provider's name, contact information, and a description of the services or treatments denied. The health plan section requires the name of the plan, the date of the denial, and a copy of the denial letter. There are two types of California Independent Medical Review Application (8 CCR 9768.10 Mandatory Form): the Standard Review and the Expedited Review. The Standard Review must be completed and submitted within 30 days of the date of the denial. The Expedited Review may be requested if the patient is facing an imminent and serious threat to their health or is facing a serious medical condition.

The California Independent Medical Review Application (8 CCR 9768.10 Mandatory Form) is a form used to request an independent review of a health plan's denial of services or treatments to a patient. The form is required when a patient disagrees with a health plan's decision and wishes to dispute the denial. It is mandated by the California Department of Managed Health Care and is used to ensure that all health plans are held accountable for their decisions. The form is divided into three sections for the patient, the attending provider, and the health plan. The patient section requires the patient's contact information, the reason for the dispute, and the requested resolution. The attending provider section requires the provider's name, contact information, and a description of the services or treatments denied. The health plan section requires the name of the plan, the date of the denial, and a copy of the denial letter. There are two types of California Independent Medical Review Application (8 CCR 9768.10 Mandatory Form): the Standard Review and the Expedited Review. The Standard Review must be completed and submitted within 30 days of the date of the denial. The Expedited Review may be requested if the patient is facing an imminent and serious threat to their health or is facing a serious medical condition.