Department of Managed Health Care Great Seal of the State of California

Independent Medical Review An Overview for the Provider

California’s Independent Medical Review (IMR) process provides patients with an opportunity to obtain an external review of treatment decisions made by HMO’s and other types of managed care organizations. Enrollees apply for an IMR through the Department of Managed Health Care. There is no cost to the enrollee. Requests for IMR are made directly to the Department with a minimum amount of administrative hassle or paperwork for the patient or providers.

Three types of health plan decisions can be reviewed through the IMR process:
  1. Denials of requested treatment considered experimental or investigational


  2. Disputes concerning the medical necessity of health care services;


    3. or

  3. Denied claims for reimbursement for medically necessary emergency or urgent care services.

Applications for IMR should be submitted within 6 months of the health plan’s decision to deny a requested service. The type of services in dispute must be a covered benefit under the enrollee’s contract. For example, nursing home services might be medically necessary but could not be decided by an IMR unless such benefits were included in the patient-HMO contract. For medical necessity and reimbursement for emergency/urgent claims, the dispute usually must first have been submitted to the plan’s grievance system before the Department will accept the case for IMR.

The Department of Managed Health Care’s IMR system is available to patients whose medical services are provided by commercial and Medi-Cal managed care plans. A similar IMR program is administered by the California Department of Insurance for other types of health insurance. You can call the California Department of insurance at 1-800-927-HELP. Patients covered by Medicare, Medicare managed care plans, Medi-Cal fee-for-service and workmen’s compensation are generally not eligible. (The Department’s toll-free assistance line can answer specific questions from patients and providers regarding eligibility at 1-888-HMO-2219.)

The independent medical review consists of a review of the pertinent medical records and patient’s history by impartial medical specialists. They provide a written decision that decides whether or not the requested service should be provided. Their determination is based on the specific needs of the patient and includes references to the medical and scientific references the reviewer has considered. If the IMR overturns the health plan’s earlier decision, the IMR decision must be implemented within 5 days.