Independent Medical Review Decisions

One of the most important ways our HMO Help Center can assist people who are having a problem with their HMO is through our Independent Medical Review program, where doctors tell HMOs what to do.

HMO problems can be very simple for us to resolve, such as fixing a paperwork error that's preventing you from getting an appointment with a specialist.

But there are some very complicated HMO problems that involve medical questions. For these cases, we provide our Independent Medical Review program, under which an independent panel of doctors decides whether an HMO was right or wrong in denying treatment.

There are two categories under which Independent Medical Reviews are used:

Medical Necessity: Independent Medical Reviews in which the disputed treatment was either delayed, denied or modified by the HMO based on medical necessity.

Experimental/Investigational: Independent Medical Reviews in which the disputed treatment was denied by the HMO as being experimental or investigational.

If the HMO's denial is overturned, it is required to pay for the requested service or treatment and we will enforce that decision to the full extent of the law.

Click on the link below to view a database of Independent Medical Review decision since the program was put into effect on January 1, 2001.

Independent Medical Review Search