How quickly are IMR decisions made?

The goals of IMR are to provide a final, impartial and medically-sound resolution of medical treatment disputes in order for medically necessary treatment to be rendered. In designing and implementing the IMR system, the Department recognized that applications for reviews must be processed as expeditiously as possible, with a minimum amount of additional delay and paperwork. After receiving an application, any additional information needed to determine IMR eligibility is obtained from the patient’s health plan within 24 hours. If necessary, the patient or providers are contacted by the most expeditious means available.

Final IMR decisions are usually issued within 30 days of the Department’s receipt of an IMR application. Providers that have requested treatment or are working with patients in evaluating treatment alternatives should be aware that reviews can be expedited if the requested treatment will be significantly less effective if it is not promptly initiated or if there is an imminent and serious threat to the health of the enrollee. Imminent and serious threats to health include, but are not limited to, serious pain, the potential loss of life, limb or major bodily function or the immediate and serious deterioration of the enrollee’s health.

Expedited reviews for Experimental or Medical Necessity IMRs can be obtained within 7 days if required by the patient’s condition or the particular circumstances of the disputed treatment.