Types of IMRs – Disputes concerning
Medical Necessity of services

A health plan enrollee can apply for a medical necessity IMR when the following conditions are met:

1. the enrollee's provider has recommended a health care service as medically necessary OR the enrollee has been seen by an in-plan provider for the diagnosis or treatment of the medical condition for which the enrollee seeks independent review;


and


2. the enrollee has filed a grievance concerning the disputed care and the plan has either upheld its initial decision or has not taken action on the grievance within 30 days.

Applicants must usually complete the HMO's grievance process or participate in the HMO's grievance process for at least 30 days. Exceptions may be granted for an expedited review if it is required due to the patient’s medical condition or prospective effectiveness of requested services.