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What is an Independent Medical Review?

How Does That Factor in With a Denied Claim?

After being denied coverage for an insurance claim based on lack of medical necessity or on grounds that the requested procedure is “experimental” or “investigational,” an insurance policyholder can request an Independent Medical Review (IMR) with the California Department of Insurance (CDI).  The CDI will appoint independent medical professionals to review the medical decisions by the insurance company and issue an opinion as to whether denial was justified.

What is an IMR?

Established in 2001, California’s Independent Medical Review process allows claimants to seek impartial review of insurance coverage denials by the California Department of Insurance.  If a coverage denial relates to emergency services, is based on a procedure being too investigational or experimental, or is based on the procedure being medically unnecessary, the policyholder can ask the CDI to review the insurance company’s decision.

The IMR is requested from, reviewed by, and processed by the CDI, rather than the insurance company itself.  The CDI will designate an IMR organization to conduct the review.  The insurance company will be required to send the designated IMR organization copies of all relevant documents, including medical records.  The organization will then review the medical decisions made by the insurance company to decide whether the requested procedure was indeed medically unnecessary and/or experimental or investigational.  The IMR will be based on standards of medical practice, the circumstances of the claimant, peer-reviewed journals and medical evidence, expert opinion, and other factors.

The CDI will adopt the recommendation of the IMR organization.  If the IMR organization concludes that the insurance company was wrong about a procedure being unnecessary or investigational, then the insurer must provide coverage for the claim.

When Can a Policyholder Request an IMR?

Independent medical review with the CDI is not available after every claim denial.  First, the claimant must typically exhaust their internal appeals within the insurance company before seeking external review.  Second, IMRs are only available for denials that are based on certain grounds.

An IMR is available to policyholders under the following circumstances:

  • The claims denied concerned emergency or urgent services
  • Health claims were denied, modified, or delayed because a regularly-covered procedure or treatment was deemed medically unnecessary
  • Health claims were denied because the requested treatment was deemed too investigational or experimental

The IMR is meant to check the medical decision making of the insurance company, not the limits of policy coverage.  If the dispute over coverage concerns interpretations of policy language or underwriting, allegations of bad faith conduct, or other matters, an IMR is not available.

An IMR may be expedited when there is a serious or imminent threat to the patient’s health.  The claimant’s healthcare provider or the CDI must certify in writing that the claimant faces a serious health risk including serious pain, the potential loss of life, limb, or major bodily function, or serious and immediate deterioration of their health.  In such circumstances, the CDI may waive the requirement that the claimant first exhaust the insurance company’s internal appeals process, and will request the IMR to make a decision as expediently as possible (within three days at most).

Get the Insurance Coverage You Paid For. Call Gianelli & Morris for Help.

If you are a California insurance policyholder or beneficiary and you have had a claim wrongfully denied, or if you have been subjected to bad faith conduct by an insurance company, call the insurance law attorneys Gianelli & Morris for a free consultation regarding your case.

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