What is the step-by-step process for requesting an Independent Medical Review (IMR) from the state if my insurer denies my appeal?

If your health insurer denies your internal appeal based on medical necessity, you can request a free Independent Medical Review (IMR) from the state. The final decision from the IMR is legally binding on your insurer. Here is the step-by-step process for requesting an IMR: Step 1: Act on Your Insurer's Final Denial Letter After denying your appeal, your insurer must send you a final denial letter. This letter is critical because it must explain your right to an IMR and include the official IMR application form and instructions for submitting it. Step 2: Complete the IMR Application Form The denial letter will identify your plan's state regulator: either the Department of Managed Health Care (DMHC) for HMOs and some PPOs, or the Department of Insurance (CDI) for most other plans. Carefully fill out the one-page IMR application form that came with the letter. Step 3: Gather Key Supporting Documents Collect copies of the denial letter, letters of medical necessity from your doctor, and any relevant test results or medical records. While your insurer is required to send your file, submitting your own documents ensures the reviewer has your most important evidence. Step 4: Submit Your Application Before the Deadline You must submit the application within six months of the date on the denial letter. You can file online at the regulator's website (dmhc.ca.gov or insurance.ca.gov), or submit by mail or fax to the address provided in the instructions. Step 5: Await the IMR Decision The regulator will confirm your eligibility and forward your case to an independent medical expert. A decision is typically made within 30 days for standard cases, or within seven days for urgent cases. If the IMR overturns the denial, your insurer must authorize the service. Important considerations: The IMR process is specifically for disputes over whether a service is medically necessary. It cannot be used for services that are explicitly not a covered benefit in your plan contract. The review is provided at no cost to you. Note: The six-month filing deadline is strict; missing it will prevent you from getting an IMR. The IMR decision is legally binding on both you and your health insurer for that specific dispute. This is general information and does not constitute legal advice. For complex situations, consult with a qualified California attorney.