Independent Medical Review (IMR)
An IMR is a review of your case by one or more doctors who are not part of your health plan or insurance. For some kinds of health coverage, this type of review may be called an Independent External Review (IER) or external review.
You do not pay anything for an IMR. If the IMR is decided in your favor, your plan must give you the service or treatment you asked for.
You may qualify for an IMR if your health plan:
- Denies, changes, or delays a service of treatment because the plan says it is not medically necessary.
- Denies an experimental treatment for a serious condition. If this happens, apply for an IMR right away. You do not have to file a complaint with your plan first.
- Will not pay for emergency or urgent care that you already received.
You can file a complaint or apply for an IMR through the agency that oversees your health coverage:
- For HMOs and many Anthem Blue Cross and Blue Shield PPOs, fill out the IMR application form for the Department of Managed Health Care (DMHC).
- Call the DMHC Help Center at 1-888-466-2219 to get a form or print one from the DMHC website.
- If you do not qualify for an IMR, the Help Center will review your case as a complaint against your health plan.
- Medicare health plan enrollees cannot get an IMR through DMHC (View more information for Medicare health plan enrollees). Contact HICAP for assistance at 1-800-434-0222.
- Medi-Cal managed care enrollees can request an IMR from DMHC for a problem regarding a health plan. But you cannot get an IMR if you already requested a State Fair Hearing for the problem. For more information on State Fair Hearings, contact the Medi-Cal Managed Care Office of the Ombudsman at 1-888-452-8609.
- For other PPOs and other types of health insurance, fill out the application form for the California Department of Insurance (CDI).
- Your insurance company is required to send you an IMR application with its denial letter. If you do not receive an application from your insurance company, you can request one from the CDI by calling 1-800-927-HELP (4357) or find the IMR application form (PDF) online.
- If your request does not qualify for an IMR, CDI will review your complaint within its complaint/mediation program.
- For health coverage that is not overseen by either DMHC or CDI, know that you also usually have the right to request some type of appeal or external review.
- Contact your health plan or coverage program for information about the complaint and appeals processes that are available to you. This information is generally included in a denial letter that you will receive from your health plan or program.