CurrentOptumPolicy N/A

Independent Medical Review request process

Describes the process and required information for requesting an Independent Medical Review from the California Department of Insurance; applies to insured individuals and their providers disputing a denied or contested health service with an insurer.

Policy Summary

PayerOptum

PolicyIndependent Medical Review request process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFile an internal appeal with the insurer and, if unresolved after a response or 30 days, submit an IMR application with required documentation and signed medical records authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysappeal wait before IMR

1 yearmedical record auth validity

4 listedexample eligible problem types

Independent Medical Review — Eligibility and Criteria

Independent Medical Review eligibility and submission criteria

Request for Independent Medical Review may be submitted to the Department of Insurance when the following process and conditions are met:

Appeal requirement: A formal appeal/complaint must first be filed with the insurer and either an unsatisfactory response received or 30 days have passed without a satisfactory resolution.30 days

Support: [[0]]

Eligible dispute types: Denial of a claim because the insurer considers the treatment or service not medically necessary or experimental (policy exclusion); insurer offering an amount lower than the policy; delays in claim filing related to a medical necessity dispute; denial of urgent or emergency services.

Support: [[1]]

Application content:

Policy Summary

PayerOptum

PolicyIndependent Medical Review request process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFile an internal appeal with the insurer and, if unresolved after a response or 30 days, submit an IMR application with required documentation and signed medical records authorization.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

What Providers and Members Must Do

Prior Authorization

Appeal before IMR

Before submitting a request for Independent Medical Review (IMR) to the Department of Insurance, the provider or member must first file a formal internal appeal/complaint with the insurer and allow the insurer to respond. If the insurer does not provide a satisfactory response, or 30 days elapse without a response, you may submit an IMR request to the Department of Insurance. A copy of the IMR request and supporting information will be provided to the insurer and to the Independent Review Organization. You (or your provider) may supply any information or documentation you believe supports your position; originals will be returned after the Department completes its review.

File a formal internal appeal/complaint with the insurer first; allow insurer response or wait 30 days before submitting IMR.
A copy of the IMR request will be sent to the insurer and the Independent Review Organization.
You have the right to provide documentation or information to support the IMR request; originals will be returned after review.

Note

Provider action — immediate steps

Provider action: preserve as an immediate action item — when an adverse determination occurs, promptly initiate the insurer’s internal appeal process and assemble the IMR packet so it can be filed promptly if the internal appeal is not resolved.

Initiate the insurer’s internal appeal as soon as an adverse determination is received.
Prepare to file IMR immediately if the internal appeal is unresolved after insurer response or 30 days.
Keep copies of all correspondence and document dates/times of communications with the insurer.

Documentation Required

Required documentation for IMR request

Include the following documentation when submitting an IMR request. The Department considers this information necessary for review and may require copies of records from the insurer and providers.

Completed IMR request form.
Name of the insurance company and policy or certificate number.
Claim number and date(s) of service at issue.
Copies of all internal appeal correspondence with the insurer (include dates and outcomes).
Clinical records supporting medical necessity (office notes, hospital records, imaging reports, operative reports).
Provider recommendation or statement explaining why the disputed service was medically necessary.
If applicable, documentation that the service was urgent/emergent and why it was medically necessary.
Signed authorization to release medical records if required by the form.
Any additional supporting materials the member or provider deems relevant (e.g., prior test results, referral notes).

Denial Risk

Triggers for IMR

Situations that commonly trigger IMR eligibility include denials that the insurer asserts are not medically necessary, denials for services the insurer characterizes as experimental or excluded, disputes over amounts payable under the policy on medical necessity grounds, delays in claim filing related to a medical necessity dispute, and denials of emergency or urgent services. Under the IMR process, one or more physicians will make a binding determination.

Denial as not medically necessary.
Denial as experimental or excluded under the policy.
Offer of a payment amount lower than the policy-specified amount on medical necessity grounds.
Delay in claim processing tied to a medical necessity dispute.
Denial of emergency or urgent services.

Key Definitions

inv-09: Medical necessity / Experimental determination

DefinitionDenial of a claim because the insurer determines the treatment or service is not medically necessary, or because it is experimental and excluded under the policy.

Examples of eligible dispute typesInsurer offering a lower amount than specified in the policy; delays in claim filing due to a medical necessity dispute; denial of urgent or emergency services.

Binding decisionUnder the Independent Medical Review process, one or more physicians will make a determination and their decision is binding on the insurer.

inv-10: Medical records authorization

DefinitionA written authorization signed by the applicant permitting disclosure of all relevant medical records, including mental health, substance abuse, and HIV records, to the insurer, the Department of Insurance, and any Independent Medical Review Organization.

Scope of disclosureAuthorizes disclosure of medical records, mental health records, substance abuse records, HIV records, diagnostic imaging reports, and other non‑documentary and nonmedical information relevant to the review.

Validity periodThis authorization expires one year after the date of signature, except for internal Department use or as otherwise permitted by law; the expiration does not apply to information previously disclosed under the authorization.

RevocationThe authorization may be revoked at any time; revocation applies only to information not previously disclosed under the authorization.

OpenPayer

Independent Medical Review request process

Independent Medical Review — Eligibility and Criteria

What Providers and Members Must Do

About Independent Medical Review (IMR)

Key Definitions

Document Dates and Review