Types of IMRs – Reimbursement for Emergency or Urgent Care

When a plan denies payment or reimbursement for claims that are based on emergency or urgent medical services, the plan determinations may be submitted for an IMR when:

1. the enrollee has received urgent care or emergency services that a provider determined was medically necessary;


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.