What Is an Independent Medical Review?

 

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.

An IMR can be requested only if the insurance company’s decision involves:

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

 

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

1-888-HMO-2219

[email protected]

Contact Form

CA Department of Insurance  

IMR – Independent Medical Review  

ONLINE complaint form insurance.ca.gov/complain 

Fillable Claim Form

 

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.

 

More Links & Resources

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  

CA Department of Insurance

Independent Medical Review (IMR) Program

Blue Shield allegation from DOI on Medical Necessity 

 

National Health Law Program 
12 page pdf on Internal Grievances & External Review in Service Denials in Covered CA Plans 

 

 

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Specimen EOC Evidence of Coverage – Appeals – Grievances

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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