What Is an Independent Medical Review?

An Independent Medical Review (IMR) is a process in which expert independent medical professionals are selected to review specific medical decisions made by the insurance company. The California Department of Insurance (CDI) administers an Independent Medical Review program that enables you, the insured, to request an impartial appraisal of medical decisions within certain guidelines as specified by the law.

Sections 10169 through 10169.5 of the California Insurance Code (CIC), which became effective January 1, 2001, explain the IMR process in detail. In addition, Section 10145.3 explains the IMR process as it relates to experimental or investigational therapies. An IMR can be requested only if the insurance company’s decision involves:

  • The medical necessity of a treatment,
  • An experimental or investigational therapy for certain medical conditions, or
  • A claims denial for emergency or urgent medical services.

It is important to note that the IMR process cannot be used for an insurance company decision that is based on a coverage issue. Only decisions regarding a disputed health care service, as it relates to the practice of medicine, that do not involve a coverage issue are qualified for the IMR program.

Unlike review procedures available through the internal appeals/grievance process of health insurance companies and health plans, the IMR request is received, reviewed, and processed by the CDI. When your request qualifies for the IMR program it is sent to the Independent Medical Review organization designated by the CDI. You are required to exhaust the internal appeals/grievance process of your particular insurance company before applying for an IMR with the CDI.  Click here to read full article on Department of Insurance Website 

 

California Health Care Foundation on IMR The California Department of Managed Health Care (DMHC)  The DMHC regulates HMOs and some PPOs in California  – Try using the Insurance Company procedure first

Complaint Form IMR

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[email protected]

Contact Form

CA Department of Insurance  

IMR – Independent Medical Review  

ONLINE complaint form insurance.ca.gov/complain  Fillable Claim Form

 

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8 comments on “Independent Medical Review

  1. What would be the appropriate venue for a Knox Keene Violation involving a disabled child.

    We are enrolled in a locally governed managed medical plan & no one seems to understand that it always applies to a disabled child.

    We passed IMR.

    They took away my kids best treatment.

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