Applying for IMR - Provider's Role

An experimental/investigational IMR must be supported with a certification from the recommending or treating physician.

While physicians and other providers cannot request an IMR on behalf of a patient, they may assist the patient in all types of IMR by ensuring medical records and any treatment authorization requests fully and accurately describe the provider's evaluation of the most appropriate treatment plan. Providers may also submit additional information concerning the requested services, the alternatives offered by the health plan or any other information that would be relevant in the IMR's assessment of the patient's needs. Any additional information not contained in the medical records previously considered by the HMO should be immediately provided to the enrollee to forward to the review organization. If necessary, the provider can contact the Department directly (toll free at 1-888-HMO-2219 or 1-888-466-2219) to ensure the information can be submitted in time for the review.

Plans and medical groups are required to provide IMR application forms to patients when they have denied services because they are considered to be experimental or investigational or when they decided an enrollee's grievance that results in a denial, modification or delay in requested services. The IMR application form is available on this web site or can be obtained by calling the HMO Help Center's toll-free number, 1-888-HMO-2219 or 1-888-466-2219. (In time-sensitive cases, the information to initiate the IMR process can be provided by phone to the Department.)