Most people seeking an independent medical review in California have already been through a frustrating process. Your doctor recommended a treatment or service. Your health insurance company denied it. You completed the required internal appeal, hoping the decision would change. Instead, you received another denial.
After going through multiple rounds of review, it is understandable to wonder whether there is anything left you can do. For many Californians, there may be.
An independent medical review (IMR) allows qualifying medical disputes to be reviewed by independent physicians rather than your health insurance company. While no outcome can ever be guaranteed, understanding the IMR process may help you avoid common mistakes and submit the strongest possible application. Knowing what information reviewers consider and how to address the reason your treatment was denied can make an important difference.
As we explain below, we recommend you reach out to a highly experienced health insurance denial attorney prior to filing an IMR because depending on your specific plan, you may have other options available.
💡 Key Takeaways
- Not every denial qualifies for an IMR:
The process generally applies to disputes over medical necessity, experimental or investigational treatment, or urgent and emergency care — not every disagreement with your health plan. - You typically need to complete an internal appeal first:
Most DMHC-regulated health plans require you to exhaust the internal appeal process before requesting an independent medical review, though expedited reviews may be available in urgent situations. - Your submission should respond directly to the denial reasoning:
A strong IMR application addresses the specific clinical guideline or policy your insurer cited, rather than simply restating that the treatment is needed. - A favorable IMR decision is binding on your health plan:
If independent physicians determine the treatment should be covered, your insurer is generally required to comply with that decision. - An unfavorable IMR isn’t necessarily the end of the road:
Depending on your health plan and the circumstances of your denial, additional legal options may still be available — which is why speaking with an attorney before and after filing can protect your position either way.
Step 1: Determine Whether Your Denial Qualifies for an Independent Medical Review
Not every health insurance denial is eligible for an IMR. The process is designed to resolve certain medical disputes, not every disagreement between a patient and a health plan. Before preparing an application, it is important to understand both why your request was denied and what type of health insurance coverage you have.
An independent medical review in California usually involves disputes over whether a treatment is medically necessary, whether it is considered experimental or investigational, or whether emergency or urgent care should have been covered. Other denials may involve billing questions, eligibility issues, or contractual coverage disputes that follow a different review process.
Your denial letter is often the best place to begin. It should explain why your request was denied, identify the clinical guidelines or policy provisions the insurer relied upon, and describe your review rights. Taking the time to understand the basis for the denial can help you determine whether an IMR is available and what information may strengthen your submission.
Not every California health plan participates in the same review process. Most health plans regulated by the California Department of Managed Health Care (DMHC) allow eligible members to request a DMHC independent medical review after completing the required internal appeal. Other types of coverage, including many self-funded employer plans governed by ERISA, Medicare, Medicare Advantage, and certain public health programs, may follow different procedures.
Step 2: Gather the Information That Supports Your Request
Once you determine that your denial may qualify for an independent medical review, the next step is gathering the information the reviewers will use to evaluate your case. Unlike your health insurance company, the independent reviewers will not know your medical history unless it is included in the materials they receive.
Start with the denial letter from your health plan, as it explains why coverage was refused and often identifies the medical policy or clinical guidelines the insurer relied upon. You should also gather your relevant medical records, test results, and your physician’s recommendation for the requested treatment or service and why it is medically necessary.
Organizing these documents before filing your IMR can help ensure the reviewers have a complete picture of your medical circumstances.
Step 3: Address the Reason Your Treatment Was Denied
A strong IMR submission does more than explain why your doctor recommended a treatment. It should also respond to the reason your health plan denied coverage.
If the denial references a specific medical policy or clinical guideline, ask your physician to review that reasoning. In many situations, responding directly to the concerns identified by the health plan may be more effective than simply submitting additional medical records.
A detailed letter from your treating physician or specialist may also strengthen your submission. Rather than simply stating that a treatment is medically necessary, the letter can explain why it is appropriate for your specific condition, why alternative treatments may not be effective, and what could happen if care is delayed. Depending on the circumstances, peer-reviewed medical literature or professional treatment guidelines may also help support your physician’s recommendation.
Your treating physician understands your medical history and why a particular treatment has been recommended. Providing that an individualized medical explanation can help the independent reviewers evaluate your circumstances, rather than relying solely on the initial coverage decision.
Step 4: Complete and Submit Your IMR Application
If your health plan is regulated by the California Department of Managed Health Care, you can generally begin the IMR process after completing the required internal appeal. In some urgent situations, you may also qualify for an expedited review.
If you are learning how to file an IMR, complete the application carefully and include the supporting medical records your reviewers will need. If you are unsure whether the DMHC regulates your health plan, your denial letter or member materials should provide that information. You can also contact your health plan and ask which external review process applies to your specific policy.
Once the DMHC determines your request is eligible, it gathers information from your health plan and sends the case to independent physicians with expertise relevant to your condition. Those reviewers evaluate the medical evidence and determine whether the requested treatment or service should be covered.
Step 5: Understand What Happens During the Review
After your application is accepted, the DMHC sends the case to independent physicians with expertise relevant to your medical condition. These reviewers evaluate the medical records, your doctor’s recommendations, and the information submitted by your health plan. In some situations, the reviewers may request additional information before reaching a decision, which is one reason it can be helpful to keep copies of everything you submit.
If the reviewers determine that the requested treatment or service should be covered, the health plan is generally required to follow the IMR decision. Although many reviews are completed within a matter of weeks, expedited reviews may be available when waiting could seriously jeopardize a patient’s health.
Step 6: Review the Decision and Understand Your Next Options
Once the independent medical review is complete, you will receive a written decision explaining the outcome. If the reviewers determine that the requested treatment or service should be covered, the health plan is required to comply with that decision.
If the IMR does not result in the outcome you hoped for, it does not necessarily mean you have exhausted every option. Depending on your health plan and the circumstances of your claim, additional legal options may still be available. Because it can be difficult to challenge an unfavorable IMR decision, many people choose to speak with an attorney before requesting an independent medical review so they fully understand how that decision could affect their case.
Talk to a California Health Insurance Denial Attorney Before Deciding Your Next Step
By the time you are considering an independent medical review, you have likely already spent weeks or months trying to obtain care your doctor believes you need. Deciding what to do next deserves careful consideration, particularly if your condition is serious or your health plan may offer options beyond the IMR process.
At the Law Offices of Scott Glovsky, we have spent decades helping Californians challenge and overturn health insurance denials while evaluating the strategy that best fits their circumstances. If you are unsure whether an independent medical review, legal action, or another approach is appropriate, we invite you to contact us online or call 626-243-5598 to discuss your situation.
References Used to Inform This Page
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