What Is an Independent Medical Review in Insurance?

Independent Medical Review (IMR) offers an impartial way to resolve disputes over denied medical services. This process involves an objective assessment by independent healthcare professionals, separate from the insurance company’s internal review. It allows individuals to challenge an insurer’s decision when a claim is denied based on medical necessity. IMR ensures a fair evaluation of medical evidence, upholding patient care standards.

Defining Independent Medical Review

Independent Medical Review (IMR) is a process where an external, impartial medical expert or panel evaluates an insurer’s decision to deny, modify, or delay a healthcare service. IMR objectively assesses the medical necessity and appropriateness of a requested treatment or service for the patient. This review is separate from the insurance company’s internal appeals process.

Reviews are conducted by unaffiliated physicians, medical specialists, or review organizations. Their independence ensures decisions are based solely on clinical evidence and established standards of care, removing conflicts of interest.

IMR focuses exclusively on the medical aspects of a case: necessity, appropriateness, and efficacy of a proposed or received healthcare service. It does not consider financial considerations, policy exclusions, or other administrative reasons for a denial. Determination rests on a thorough review of the patient’s medical records, treating physician’s recommendations, and applicable clinical practice guidelines.

The distinction between IMR and an internal appeal is important for navigating denied claims. While an internal appeal is conducted by the insurer, an IMR introduces a neutral third party whose professional opinion carries weight. This external review ensures medical decisions are grounded in sound clinical judgment.

Initiating an Independent Medical Review

Individuals typically initiate an Independent Medical Review after exhausting their health plan’s internal appeal process and services remain denied. Common IMR triggers include denials based on lack of medical necessity, experimental treatment classification, or care appropriateness questions. Individuals usually have a limited timeframe, often four to six months from the final internal adverse determination, to request IMR.

The patient or authorized representative (e.g., family member, legal guardian, treating physician) can request IMR. The request must be submitted to the appropriate independent review organization, which varies by health plan.

IMR submission requires specific documentation. This includes all relevant medical records for the denied service (e.g., physician’s notes, test results, treatment plans). Also include the initial denial letter from the insurer and related internal appeal correspondence, detailing denial reasons.

Obtaining IMR forms typically involves contacting the state’s department of insurance or designated independent review entity. These forms collect essential information about the patient, health plan, denied service, and provider. Accurate completion of these fields is important, as omissions or errors could delay the review.

Forms often require detailed explanations of why the patient believes the denied service is medically necessary, supported by treating physician statements. Submitting all requested documentation clearly and organized helps the independent medical reviewer efficiently assess the case. Timely submission of a complete request package is important to avoid forfeiture of the IMR right.

The Independent Medical Review Process

After an IMR request and supporting documentation are submitted, the independent review organization begins its actions. It first processes the complete application package, ensuring all required forms and medical records are present. Missing information may prompt a request for further documentation from the patient or health plan.

A qualified independent medical reviewer or panel is assigned based on the medical specialty of the denied service. For instance, a cardiac procedure denial is typically reviewed by a cardiologist. Reviewers are selected for their expertise and lack of financial or professional ties, ensuring review independence.

The assigned reviewer(s) thoroughly examine all submitted materials: patient’s medical records, treating physician’s recommendations, and the health plan’s denial rationale. They also consider generally accepted medical standards and clinical practice guidelines for the patient’s condition and proposed treatment.

During the review, the independent organization may communicate with the health plan or patient’s treating physician for additional information or clarification. Such requests are time-sensitive, requiring prompt responses to avoid delays.

The IMR process typically concludes within a defined timeframe, often 30 to 45 days for standard reviews. Expedited reviews for urgent cases may be completed within 72 hours. The reviewer(s) then render a decision based on their medical judgment and evidence. This decision is communicated to both the patient and the health plan, outlining the findings and basis for the determination.

Outcomes of Independent Medical Review

The IMR process culminates in a decision to either uphold or overturn the insurer’s denial, finding the service medically necessary. If the independent medical reviewer determines the denied service is medically necessary, the insurer’s denial is overturned. The health plan is then typically obligated to cover the denied treatment or service.

Conversely, if the independent medical reviewer agrees with the insurer’s assessment, the denial is upheld. In such instances, the health plan is not required to cover the service, as the external review validated their decision. The outcome is based solely on presented medical evidence and clinical standards.

The decision rendered by the independent medical review organization is generally binding on the health plan. If the denial is overturned, the insurer must comply with the IMR decision and authorize or pay for the service. This binding nature helps ensure an independent, expert opinion can compel coverage.

While the decision is typically binding on the insurer, it is usually not binding on the patient. If the IMR upholds the denial, the patient generally retains the option to pursue other avenues, though these fall outside the administrative review process. The IMR decision represents the final administrative determination concerning the service’s medical necessity.

Following an IMR decision, both the patient and the health plan receive official notification of the outcome. If the denial is overturned, the health plan proceeds with processing the claim for coverage. The IMR process provides a clear path forward for individuals facing denied medical claims.

Citations

California Department of Managed Health Care. “Independent Medical Review (IMR) Program.” Accessed August 30, 2025.
New York State Department of Financial Services. “External Appeal: How to File a Request.” Accessed August 30, 2025.