CA FORN A DEPARTMENT OF NSURANCE
CONSUMER ADVISORY
DAV E JONE S, NS UR AN CE C OM M S S O NE R
CHALLENGING DENIALS OF HEALTH CLAIMS AND REQUESTING
AN INDEPENDENT REVIEW
If an insurance company denies a request or claim for medical treatment, insureds have the right to appeal to the
company and also to then ask the Department of Insurance to review the denial. These actions often succeed
in obtaining needed medical treatment, so a denial by an insurer is not the nal word. You may le a Request for
Assistance with the Department of Insurance whenever you have problems with an insurer involving a claim.
Independent Medical Review: If your claim has been denied because the insurer determined the treatment is
not medically necessary or was experimental, you may request an Independent Medical Review (IMR) from the
Department of Insurance at no cost to you. However, you must rst le an appeal of the denial with your insurance
company.
First Steps: Appeal the denial using the insurance company’s internal appeals/grievance process.
• Find out the reason for the denial and review the policy language supporting the denial
• Submit all necessary support for treatment, with doctors statements and medical records
• Provide research showing the treatment requested is accepted and appropriate, if possible.
IMR Deadlines: If the insurance company upholds its decision or is delaying in responding to the appeal/grievance,
then le a Request for Assistance or an IMR request with the California Department of Insurance (CDI). This request
must be made within 6 months of the insurance company upholding its decision on appeal.
Getting Independent Medical Review: In this process, expert independent medical professionals review the medical
decisions made by the insurance company, and often decide in favor of the insured getting the medical treatment
requested.
An IMR can be requested if the insurance company’s decision involves:
• Health claims that have been denied, modied, or delayed by the insurance company because a covered
service or treatment was not considered medically necessary;
• Health claims that have been denied for urgent or emergency services that a provider recommended was
medically necessary;
• Health claims that have been denied as being investigational or experimental
therapies.
6 Easy Steps to IMR:
1. Notify CDI to request an IMR by lling out this application.
2. Agree and provide written consent to participate in IMR.
3. The CDI determines if the request is eligible for IMR.
4. The IMR Organization will have 30 days to review once all information is
gathered—unless the request involves an imminent and serious threat to
health, which can be expedited and a decision rendered in 3 days.
5. The IMR organization will send the decision to the insured, the insurance
company, and the Insurance Commissioner.
6. The Commissioner will adopt the recommendation of the IMR organization
and promptly notify the insured and the insurance company; the decision
is binding on the insurance company.
Reviewing Coverage Denials: If the company denies treatment as not a covered
benet, or if CDI nds that the issue does not involve a disputed health care
service, CDI will review the company’s decision for correctness.
