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:
- 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
ONLINE complaint form insurance.ca.gov/complain
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.
Video's trying to explain Medical Necessity
More Links & Resources
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.
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
- 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