What Is California's Independent Medical Review?
Independent Medical Review (IMR) is a California state program that allows you to have an independent physician review your health plan's decision to deny, delay, or modify your medical treatment. Unlike internal appeals (which are reviewed by the same insurance company that denied you), IMR is conducted by physicians who have no connection to your health plan.
Under Cal. Health & Safety Code § 1374.30, IMR decisions are binding on
health plans. If the IMR reviewer determines your treatment should be covered, your health
plan MUST authorize and pay for it. There is no further appeal for the insurer.
Who Administers IMR in California?
The California Department of Managed Health Care (DMHC) administers the IMR program for most health plans. If you have a PPO plan regulated by the California Department of Insurance (CDI), a similar external review process applies. This guide focuses on the DMHC IMR process, which covers most Californians.
What Types of Denials Can Be Reviewed?
IMR can review denials based on "medical necessity" - meaning the health plan claims the treatment isn't needed, isn't appropriate, or is experimental. Specifically, IMR covers:
- Medical necessity denials: Plan says treatment isn't medically necessary
- Experimental/investigational denials: Plan claims treatment is not proven
- Urgency disputes: Plan won't authorize care as quickly as your doctor recommends
- Out-of-network denials: When in-network providers aren't available for your condition
IMR cannot review benefit interpretation disputes (e.g., "your plan doesn't cover acupuncture at all") or billing disputes. For those issues, you would file a complaint with DMHC instead of requesting IMR. IMR is specifically for medical necessity decisions.
Am I Eligible for IMR?
Most Californians with health plan coverage can use IMR. Here's how to determine if you qualify:
Plans Covered by DMHC IMR
- HMO plans: All HMOs licensed in California
- POS plans: Point-of-Service plans from licensed health plans
- Some PPO plans: PPOs issued by health care service plans (not insurance companies)
- Covered California plans: All marketplace plans (HMO and PPO)
- Medi-Cal managed care: Most Medi-Cal managed care plans
Look at your health plan ID card or Evidence of Coverage. If it says "Regulated by the Department of Managed Health Care," you're covered by DMHC and can use IMR. If it says "Regulated by the California Department of Insurance," you'll use CDI's external review process instead (similar but separate).
Timing Requirements
You generally must file for IMR within 6 months of receiving your denial letter. However, you should act quickly - especially for urgent medical situations.
Do I Need to Complete Internal Appeals First?
In most cases, yes - you need to complete at least one level of internal appeal before requesting IMR. However, there are important exceptions:
- Urgent situations: If waiting for internal appeal would seriously jeopardize your health
- Plan missed deadlines: If the health plan didn't respond to your grievance within required timeframes
- DMHC waiver: The DMHC can waive the internal appeal requirement in certain circumstances
How to File for Independent Medical Review
Filing for IMR is free and relatively straightforward. Here's the step-by-step process:
Complete Internal Appeal (Usually Required)
File a grievance with your health plan first. The plan must respond within 30 days (or 3 days for urgent cases). Keep copies of everything you submit and receive.
Gather Your Documents
Collect: your denial letter, internal appeal decision, Evidence of Coverage, medical records supporting your need for treatment, and a letter from your treating physician explaining why the treatment is necessary.
Complete the IMR Application
Download the IMR application from DMHC's website or call the DMHC Help Center at 1-888-466-2219. You can file online, by mail, or by fax.
Submit Supporting Documentation
Include all relevant medical records, your doctor's statement of medical necessity, and any published medical literature supporting the treatment. The more documentation you provide, the better.
Wait for the Decision
DMHC will assign your case to independent physician reviewers who specialize in your medical condition. Standard cases are decided within 30 days; urgent cases within 3-7 days.
The most important document in your IMR is a detailed letter from your treating physician explaining why the denied treatment is medically necessary for YOUR specific situation. Generic letters don't work as well. Ask your doctor to explain what other treatments have been tried, why they failed, and why this treatment is the appropriate next step.
IMR Timelines and Deadlines
California law sets strict timelines for the IMR process. Here's what to expect:
| Stage | Timeline | Notes |
|---|---|---|
| Filing deadline | 6 months | From date of final denial letter |
| DMHC eligibility review | 3 days | DMHC determines if your case qualifies |
| Plan must submit records | 3 days | After DMHC accepts your IMR request |
| Standard IMR decision | 30 days | Most non-urgent cases |
| Expedited IMR decision | 3-7 days | For urgent/imminent health issues |
| Plan must comply | 5 days | After receiving IMR decision in your favor |
Under Cal. Health & Safety Code § 1374.33, you can request expedited IMR
if your doctor certifies that the standard timeframe would seriously jeopardize your life,
health, or ability to regain maximum function. Expedited reviews must be completed within
3 days (or up to 7 days for experimental treatments).
What Happens After the IMR Decision?
If You Win (IMR Overturns the Denial)
If the independent reviewers determine your treatment should be covered, your health plan MUST authorize the treatment promptly - typically within 5 business days. The plan cannot appeal the IMR decision. If the plan fails to comply, contact DMHC immediately.
- Health plan must authorize the treatment within 5 business days
- Plan must pay for the treatment according to your policy terms
- If you already paid out-of-pocket, you can seek reimbursement
- Plan cannot retaliate or increase your premiums based on the IMR
If You Lose (IMR Upholds the Denial)
If the IMR upholds your health plan's denial, your options are more limited but not zero:
- New evidence: If you have new medical information, you may be able to request another IMR
- Different treatment: Work with your doctor on alternative treatment approaches
- Lawsuit: You can still sue your health plan, though the IMR decision will be considered
- Policy change: Check if your plan or your medical condition has changed in ways that might affect future requests
If your condition worsens, you try other treatments that fail, or new medical evidence emerges, you may have grounds for a new IMR request. Document everything and work with your treating physician to build the strongest possible case.
Tips for Winning Your IMR
Based on my experience helping clients with health insurance appeals, here are the most important factors in winning an IMR:
1. Get a Strong Letter from Your Doctor
This is the single most important factor. Your doctor's letter should explain:
- Your specific diagnosis and medical history
- What treatments you've already tried and why they didn't work
- Why the denied treatment is medically necessary for YOU (not just in general)
- What will happen if you don't receive this treatment
- Citations to medical literature supporting the treatment
2. Include Peer-Reviewed Medical Literature
If your treatment is supported by published medical studies, include them. This is especially important for newer treatments or when challenging "experimental" denials. Focus on recent studies from reputable medical journals.
3. Document Failed Treatments
Insurers often deny coverage for treatments when "step therapy" hasn't been completed. Make sure your records clearly show what treatments you've tried and why they failed or weren't appropriate for your condition.
4. Be Specific About Your Situation
Generic arguments don't win IMRs. Explain why THIS treatment is necessary for YOUR specific medical situation. The reviewers need to understand your individual case.
IMR Application Checklist
- Completed DMHC IMR application form
- Copy of your health plan denial letter
- Copy of your internal appeal and the plan's response
- Detailed letter from your treating physician
- Relevant medical records and test results
- Peer-reviewed medical literature (if available)
- Your Evidence of Coverage (policy documents)
- Personal statement explaining your situation (optional but helpful)
Common Types of IMR Cases
Mental Health Treatment Denials
Mental health parity violations are common in California. If your health plan is denying residential treatment, intensive outpatient programs, or ongoing therapy, IMR can help. Make sure to cite California's mental health parity laws in addition to federal MHPAEA.
Cancer Treatment Denials
Insurers frequently deny newer cancer treatments as "experimental." California has strong protections for cancer patients, and IMR reviewers often overturn these denials when there's supporting medical evidence.
Orthopedic Surgery Denials
Denials for joint replacements, spinal surgeries, and other orthopedic procedures are common. Document failed conservative treatments (physical therapy, injections, etc.) thoroughly.
Medication Denials
When health plans deny specific medications (especially newer, expensive ones), IMR can review whether the denial was appropriate. Include documentation of why alternatives aren't suitable for your condition.
Under Cal. Health & Safety Code § 1367.03, California health plans must
provide timely access to care. If in-network providers aren't available within required
timeframes, the plan may have to authorize out-of-network care at in-network rates.
This can be challenged through IMR if the plan denies the out-of-network authorization.
Need Help With Your California IMR?
I help California residents navigate the IMR process. Whether you need help drafting your application, gathering supporting documentation, or understanding a complex denial, I can help you build the strongest possible case.