CurrentmhnPolicy N/A

Knox-Keene plan appeal rights (Dental Managed Care)

Explains appeal and review rights for members of the Knox-Keene dental managed care plan in California, including Independent Medical Review (IMR) and state hearing procedures, who may request them, timelines, and contact methods.

Policy Summary

Payermhn

PolicyKnox-Keene plan appeal rights (Dental Managed Care)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMembers may request IMR or a state hearing; to preserve continuation of disputed services during a state hearing, submit the request within 10 days of the adverse decision.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

180IMR request deadline (days)

120State hearing request deadline (days)

10Request continuation (stay) deadline (days)

no costMember cost for IMR/state hearing

3 daysExpedited hearing decision target

Appeal and Review Criteria

Appeal and review criteria and procedures

Procedures for appeals and reviews available to members after an adverse decision by the dental plan.

Members should first use the dental plan's internal grievance/appeal process before seeking external review or a state hearing; using the plan's appeal process does not waive any legal rights or remedies.

Independent Medical Review (IMR): Member may request an Independent Medical Review (IMR) to have an external, plan‑independent reviewer assess medical necessity, experimental/investigational status, or disputed payments; IMR must be requested within 180 days of the adverse decision. DMHC provides forms, information, and free assistance (phone and TTY numbers).

State hearing — timing: Member may request a state hearing within 120 days of the adverse decision. If the member requests continuation of disputed services (a stay) pending the state hearing, the state hearing request must be submitted within 10 days of the adverse decision.

Policy Summary

Payermhn

PolicyKnox-Keene plan appeal rights (Dental Managed Care)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMembers may request IMR or a state hearing; to preserve continuation of disputed services during a state hearing, submit the request within 10 days of the adverse decision.

SourceLink

On This Page

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Member Requests and Continuation of Services

Prior Authorization

Member appeal and continuation requests (IMR and state hearing timelines)

Members may pursue either an Independent Medical Review (IMR) or a state hearing after an adverse decision; to preserve continuation of disputed services (stay) during a state hearing, the member must request the state hearing within 10 days of the adverse decision. Members do not pay for IMR or state hearings. Contact and submission methods for state hearing requests (online, phone, mail, fax) are provided by the state hearing office.

Request IMR within 180 days of the adverse decision (see IMR instructions and DMHC contact info).
Request a state hearing within 120 days of the adverse decision, or within 10 days if requesting continuation of disputed services pending the hearing.
State hearing applications can be submitted online, by phone, by mail (address provided), or by fax (numbers provided).
Members do not have to pay for IMR or state hearings.

Key Definitions: IMR and State Hearing

inv-03: IMR — Independent Medical Review (IMR) definition and purpose

DefinitionIndependent Medical Review (IMR) is an external review, independent of the dental plan, that assesses medical necessity, whether a treatment is experimental or investigational, and disputes over emergency or other coverage/payment decisions.

Who can request IMRA member who receives an adverse decision from the dental plan may request IMR; members should first use the plan's grievance/appeal process and may contact the Department for assistance if unresolved.

Deadline to requestMust be requested within 180 days of the date the adverse decision notice was issued.

How to get help or formsDMHC provides application forms, instructions, a toll-free number (1-888-466-2219) and TDD (1-877-688-9891); website: www.dmhc.ca.gov.

Scope of reviewIMR reviews the plan's determinations about medical necessity, coverage for experimental/investigational treatments, and disputes about emergency or service payment decisions.

inv-04: State hearing — definition, relationship to IMR, and relevant timelines/expedited hearing criteria.

DefinitionState hearing is an administrative hearing before a judge to review the member's case regarding an adverse decision by the dental plan.

Relationship to IMRA member may request a state hearing separately from IMR; if a state hearing has already been held, IMR may not be available (IMR is an alternate external review route).

Standard deadline to requestMust be requested within 120 days of the date the adverse decision notice was issued.

Deadline to request continuation (stay)If you want the dental plan to continue disputed services (receive 'continued benefits') pending the state hearing decision, you must request the state hearing within 10 days of the adverse decision notice and notify the dental plan you want continued benefits.

Expedited hearing optionIf waiting up to 90 days would seriously harm your health or dental function, you can request an expedited decision and may receive a decision within 3 days; include a supporting statement from your treating dentist or the plan explaining the harm.

How to apply