The Independent Medical Review Program

All insurance company decisions involving a disputed health care service are eligible for an IMR as long as they qualify under the following three categories: • Health claims that have been denied, modified, or delayed by the insurance company because a regularly covered service or treatment was not considered medically necessary; • Health claims that have been denied for urgent or emergency services; or • Health claims that have been denied for investigational or experimental therapies. You can request an IMR when services or treatments have either been performed or when they have been recommended by your health care provider (a pre authorization denial). All other insurance company decisions that are not included in the above three categories are not eligible for an IMR. These decisions may include, but are not limited to, the following: • Health claims that have been denied by the insurance company because the service or treatment is not covered under the insurance contract. Denials due to coverage issues or other related underwriting policy issues do not qualify for the IMR program. • Legal interpretations of policy language, provisions, and terms do not qualify for the IMR program. • Bad faith allegations and other demands for extra payments under the health insurance contract do not qualify for the IMR program. 3 What issues are eligible for an Independent Medical Review? What issues are not eligible for an Independent Medical Review?