Independent Medical Review (IMR) in California
Denied treatment, medication, surgery, or a specialist referral? You may have the right to challenge the denial through an Independent Medical Review.
This page gives you a simple overview of what IMR is, when it may apply, what documents to gather, and what to do next if your health plan says no.
What Is IMR?
An Independent Medical Review is an outside review of certain health plan denials. It is designed for situations where the issue is medical necessity, a disputed treatment decision, or in some cases a denial involving experimental or investigational care.
We have tons of detail if you scroll all the way down the page…
Common IMR Problems
- Treatment denied as not medically necessary
- Medication or infusion not approved
- Surgery or procedure denied
- Referral to a specialist refused
- Hospital or outpatient care delayed
Why This Matters
Many people stop after the first denial letter. But a denial is not always the final answer. The right next step depends on the type of coverage, the reason for the denial, and whether the situation is urgent.
Quick Checklist: Might IMR Apply?
You may want to look into IMR if one or more of these happened:
- Your doctor recommended care but the plan denied it
- The denial says not medically necessary
- The plan delayed approval too long
- You were denied a drug, treatment, or procedure
- You received a denial letter or adverse determination
- You believe the plan used the wrong medical standard
- Your condition is serious and cannot wait
- You are unsure whether to file an appeal, grievance, or IMR
What To Do First
- Read the denial letter carefully
- Find out exactly why the plan denied the service
- Save the Explanation of Benefits (EOB) and plan notices
- Ask your doctor for chart notes or a written medical reason
- Keep copies of every letter, fax, upload, and phone note
Helpful Documents To Gather
- Denial letter or notice of action
- Explanation of Benefits (EOB)
- Doctor’s recommendation or prescription
- Medical records or chart notes
- Your health plan member ID card and plan name
Two Important California Paths
DMHC-Regulated Health Plans
Many California HMOs and some other managed care plans fall under the Department of Managed Health Care. In many cases, the member first files a grievance with the plan.
If the issue is unresolved after the plan process, or if the case is urgent, the next step may be to seek help through DMHC.
CDI-Regulated Insurance Coverage
Some PPO and insurance-company products are overseen by the California Department of Insurance, which also has an IMR program.
The paperwork and path can look different depending on the policy, so identifying the regulator is an important first step.
Urgent Situation?
If the medical issue is serious, time-sensitive, or involves a delay that could affect health, do not treat it like ordinary paperwork. Gather your documents right away and review the denial path as soon as possible.
Need Help Figuring Out The Next Step?
We may be able to help you sort out whether your issue looks more like a grievance, appeal, or Independent Medical Review situation, and whether your coverage appears to fall under DMHC or CDI.
This page is for general educational information only and is not legal advice. Appeal rights, deadlines, and review options can vary based on the type of health coverage, the regulator, and the reason for the denial.
Independent Medical #Review (IMR) Program
See our Main Webpage on IMR
Denied Medical Care or Treatment?
You may have the right to file an Independent Medical Review (IMR) or appeal a denial.
If your health plan said a treatment, procedure, medication, or referral was not medically necessary, denied as not covered, or delayed too long, do not assume the answer is final. In California, some denials can be challenged through the plan’s appeal process and, in some situations, through an Independent Medical Review.
Common Denial Problems
- “Not medically necessary”
- Referral or treatment denied
- Drug or procedure not approved
- Hospital or specialist issue
- Delays in authorization
What Is IMR?
An Independent Medical Review is a process where an outside reviewer looks at whether your health plan should cover the care or treatment that was denied.
Why Start Here?
Many people land on this page because they are overwhelmed. This section helps you figure out the next step before you dig through legal links, agency forms, and plan language.
Quick IMR / Appeal Checklist
You may need an appeal or Independent Medical Review if one or more of these happened:
- Your health plan denied a service or procedure
- Your doctor says you need care, but the plan disagrees
- A medication or treatment was refused
- The plan says the service is not medically necessary
- You received a denial letter or adverse determination
- The plan delayed care too long
- You want to know whether to appeal first or seek outside review
- You are not sure what kind of coverage rules apply
Helpful first step: Gather your denial letter, Explanation of Benefits (EOB), doctor’s recommendation, and any plan notices before starting the appeal or review process.
This information is general and educational. Appeal rights, timelines, and review options depend on the type of health coverage and the reason for the denial.
VIDEO's
DMHC Help Center & Independent Medical Review VIDEO
See our Main Webpage on IMR
An Independent Medical Review (IMR) is where expert independent medical professionals 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.
Health insurer delayed her MRI. Meanwhile, the cancer that would kill her was growing.
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.
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
- IMR on CA Department of Insurance Website
- Medi Cal Managed Care IMR Appeals Disability Rights.org
- What Is an Independent Medical Review?
- Who Can Request an Independent Medical Review?
- When Can an Independent Medical Review Be Requested?
- What Issues Are Eligible for an Independent Medical Review?
- What Issues Are Not Eligible for an Independent Medical Review?
- How Does the Independent Medical Review Program Work?
- What Are the Criteria Used in an Independent Medical Review Determination?
- Is There a Way to Process an Independent Medical Review More Quickly in Extraordinary Circumstances?
- Will an Independent Medical Review be Costly?
- Does Independent Medical Review Participation Prevent Future Legal Action?
- Are Medical Records Kept Confidential in the Independent Medical Review Process?
- How Do I Request an Independent Medical Review from the California Department of Insurance?
- Health Insurance Terms and Phrases
- 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
- 1-888-HMO-2219
- [email protected]
- CA Department of Insurance
- IMR – Independent Medical Review
- ONLINE complaint form insurance.ca.gov/complain
- Magellan Mental Health
- Policy Statement
- Magellan* provides procedures for the expeditious processing of requests for external appeal of adverse determinations through an Independent Review Organization as required by applicable law or customer contract.
- Purpose
- To establish standards to assure independent and timely review of disputed health care services to assure that appropriate, beneficial treatment interventions are made available to members. Magellan Mental Health
-
Ten Years of California’s Independent Medical Review Process: A Look Back and Prospects
for Change Chcf.org - National Health Law Program 12 page pdf on Internal Grievances & External Review in Service Denials in Covered CA Plans
- 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.
Our Web Pages on
- Medical Necessity – reasonable and necessary Independent Medical Review
- Appeal & Grievances? Medicare – Medi Cal – Covered CA
FAQ’s “Independent Medical Review”
- latimes.com/investigation-delays-los-angeles-hospitals-patients-deaths
- Knox Keene violations
- Evidence of Coverage
- California Children’s Services Whole Child Model dhcs.ca.gov/CCS Whole Child Model
- Evidence of Coverage
- Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a clinical diagnosis given to children who have a dramatic – sometimes overnight – onset of neuropsychiatric symptoms including obsessions/compulsions or food restriction. They are often diagnosed with obsessive-compulsive disorder (OCD) or an eating disorder, but the sudden onset of symptoms separates PANS from these other disorders. In addition, they may have symptoms of depression, irritability, anxiety, and have difficulty with schoolwork. The cause of PANS is unknown in most cases but is thought to be triggered by infections, metabolic disturbances, and other inflammatory reactions. med.stanford.edu/pans
- Air Ambulance?
Prior #Authorization
- Preauthorization is A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary. Sometimes called prior authorization, prior approval or precertification.
- Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. Health Net Glossary * See also YOUR EOC, Evidence of Coverage!
- IMHO Insurance Companies are not doctors and a lot of people and regulators agree, thus the pending laws and investigations.
- Exhausted by prior authorization, many patients abandon care: AMA survey
- Prior Authorization in Medicare Advantage Plans: How Often Is It Used? KFF 10/2018
- Prior Authorization - Regulatory Investigation aka “preauthorization” and “precertification” KFF.org 5.20.2022
- California Senate Bill 250 * Senator Pan would require that insurers consult with doctors on which services require authorizations, streamline the process, less paperwork and allow patients to get the care they need faster.
- SB 250 would require health plans to exempt physicians from prior authorization rules if they have practiced within the plan's criteria 80% of the time. CMA.Docs.org
- PRIOR AUTHORIZATION REQUIREMENTS HALTED FOR CERTAIN SERVICES
- Parody If Health Care was honest VIDEO
- UnitedHealth launches ‘gold card' to ease prior authorization burden
- Use of Prior Authorization Up in Medicare Advantage Plans, Senate Report Finds
- ajmc.com/prior-authorizations-and-the-adverse-impact-on-continuity-of-care
- See our main webpage on Medical Necessity
Resources, Links & Bibliography
- cal matters.org/new-bill-pushes-insurers-to-stop-playing-doctor
- Payer Denial Tactics — How to Confront a $20 Billion Problem
- cal matters.org/richard-pan
- cma docs.org/prior-authorization-bill
- Plaintiff whose insurer delayed surgery is awarded $14 million over opioid dependency
- SCAN Pharmacy Prior Authorization Forms SCAN Website
- General Prior Authorization SCAN Website
- Her spine surgery was denied. Doctors say it's all too common.
Insurance denied 18-year-old Nala White’s surgery for degenerative disc disease. After NBC News reached out, it was approved the next day. NBC News.com