Level 2 appeal

Here is the step-by-step process for Level 2 Appeal.

Step 1 – The Independent Review Organization reviews your appeal.

For medical coverage

A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan.

Medicare Level 2 appeals

You do not need to request the Level 2 Appeal. We will automatically send any denials (in whole or in part) to the Independent Review Entity (IRE). You will be notified when this happens.

The Independent Review Entity must give you an answer to your Level 2 Appeal within 30 calendar days of when it gets your appeal. This rule applies if you sent your appeal before getting medical services or items.

If you had "fast appeal" at Level 1, you will automatically have a fast appeal at Level 2. The review organization must give you an answer within 72 hours of when it gets your appeal. However, if the Independent Review Entity needs to gather more information that may benefit you, it can take up to 14 more calendar days. If the IRE needs extra days to make a decision, it will tell you by letter.

Medi-Cal Level 2 appeals

There are two ways to make a Level 2 appeal for Medi-Cal services and items: Independent Medical Review (IMR) or State Fair Hearing.

  1. Independent Medical Review

    You can ask for an Independent Medical Review (IMR) within 6 months after we send you a written decision. You may ask for an IMR from the Help Center at the California Department of Managed Health Care (DMHC). An IMR is available for any Medi-Cal covered service or item that is medical in nature. An IMR is a review of your case by doctors who are not part of our plan. If the IMR is decided in your favor, we must give you the service or item you requested. You pay no costs for an IMR.

    To request an IMR:

    • Fill out the Complaint/Independent Medical Review (IMR) Application Form available at the Department of Managed Health Care (DMHC) website or call the DMHC Help Center at (888) 466-2219 (TDD: (877) 688-9891).
    • If you have them, attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.
    • Fill out the Authorized Assistant Form if someone is helping you with your IMR appeal. You can get the form at the DMHC website or by calling the DMHC Help Center at (888) 466-2219 (TDD: (877) 688-9891).
    • Mail or fax your forms and any attachments to:
        Fax: (916) 255-5241
        Help Center
      Department of Managed Health Care
      980 Ninth Street, Suite 500
      Sacramento, CA 95814-2725

     

  2. State Fair Hearing

    You can request a State Fair Hearing for Medi-Cal covered services and items (including IHSS). In most cases you must first file an appeal with the plan before requesting a State Fair Hearing. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have, you have the right to ask for a State Fair Hearing.

    In most cases you have 120 days to ask for a State Fair Hearing after the “Your Hearing Rights” notice is mailed to you. You have a much shorter time to ask for a hearing if your benefits are being changed or taken away.

    You can ask for a State Fair Hearing via a phone call, fax, mail, email or online:
      Phone: (800) 743-8525 (TDD: (800) 952-8349)
      Fax: (833)281-0905
      Email: SCOPEOFBENEFITS@DSS.CA.GOV
      Online: www.cdss.ca.gov
      California Department of Social Services
    State Hearings Division
    P.O. Box 944243, Mail Station 9-17-37
    Sacramento, California 94244-2430

For drug coverage

If you want the Independent Review Entity to review your case, your appeal request must be in writing. The letter we send about our decision in the Level 1 Appeal will explain how to request the Level 2 Appeal.

Standard appeal

  • If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal.
  • If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision.
  • If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision.

Fast appeal

  • If the review organization agrees to give you a “fast appeal,” it must give you an answer to your Level 2 Appeal within 72 hours after getting your appeal request.
  • If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 24 hours after we get the decision.

Step 2 – The Independent Review Organization gives you their answer

If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision.

  • If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IRE’s decision.
  • If the Independent Review Entity says No to part or all of what you asked for, it means they agree with the Level 1 decision. This is called "upholding the decision." It is also called "turning down your appeal."

If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining the decision made by the doctors who reviewed your case.

  • If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment.
  • If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. You can still get a State Fair Hearing.
  • If your Level 2 Appeal was a State Fair Hearing, the California Department of Social Services will send you a letter explaining its decision.
  • If the State Fair Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision.
  • If the State Fair Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. We may stop any aid paid pending you are receiving.

Step 3 – If your case meets the requirements, you choose whether you want to take your appeal further (Level 3)

For medical coverage

  • If your Level 2 Appeal was an Independent Medical Review, you can request a State Fair Hearing.
  • If your Level 2 Appeal was a State Fair Hearing, you may ask for a rehearing within 30 days after you receive the decision. You may also ask for judicial review of a State Fair Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you receive the decision. You cannot ask for an IMR if you already had a State Fair Hearing on the same issue.
  • If your Level 2 Appeal went to the Medicare Independent Review Entity (IRE), you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. The letter you get from the IRE will explain additional appeal rights you may have.

For drug coverage

If the Independent Review Entity says No to your Level 2 Appeal, it means the Independent Review Entity agrees with our decision not to approve your request. This is called “upholding the decision”. It is also called “turning down your appeal.

If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. The Level 3 Appeal is handled by an administrative law judge.

 

For appeals for Hospital discharge dates, covering other services like skilled nursing, outpatient services and home health care, please refer to Evidence of Coverage (EOC) / Member Handbook, Chapter 9, sections 7 through 10, or call Blue Shield of California Promise Health Plan Member Services.

 

You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Member Services at (855) 905-3825 [TTY: 711], 8 a.m. – 8 p.m., seven days a week.