The Independent Medical Review Program

1 What Is An Independent Medical Review? An Independent Medical Review (IMR) is a process in which expert independentmedical professionalsareselectedtoreview specific medical decisions made by the insuring 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, and 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.