What is Independent Medical Review (IMR)?
If a medical treatment requested by your treating physician is delayed, modified, or denied through Utilization Review (UR), you have the right to request an Independent Medical Review (IMR). IMR allows an independent panel of medical professionals to determine if the requested treatment is medically necessary.
Step 1: Receive Utilization Review (UR) Decision
Before you can apply for an IMR, your treating doctor’s treatment request must go through Utilization Review:
- Written Notice: If the insurance company’s UR physician modifies, delays, or denies the treatment request, they must send you and your doctor a written UR decision letter within 5 business days of the request.
- IMR Application Included: Attached to the UR decision letter, the insurer must provide an official Application for Independent Medical Review form (DWC Form IMR).
Step 2: Submit the IMR Application
To challenge the UR decision, you or your representative must file the official application promptly:
- Fill Out the Form: Complete the Application for Independent Medical Review. Make sure to sign and date the form.
- Strict 30-Day Deadline: Mail or fax the completed application to the designated IMR organization (Maximums/DWC) within 30 calendar days from the date the UR decision was mailed to you.
- Include UR Decision: Attach a copy of the UR denial or modification letter with your application submission.
- No Filing Fee: There is no fee for the injured worker to request an IMR; all costs are paid by the employer/claims administrator.
Step 3: Review & Final Determination
Once the application is received and validated, the medical review process begins:
| Stage |
Process Details |
Timeline |
| 1. Eligibility Check |
The DWC verifies if the dispute is eligible for IMR review. |
~10 to 15 Days |
| 2. Records Submission |
The claims administrator is notified to send all relevant medical records to the independent review organization. |
15 Days from Notice |
| 3. Doctor Review |
An independent licensed physician reviews the records against California Medical Treatment Utilization Schedule (MTUS) guidelines. |
30 Days from Records Receipt |
| 4. Final Decision |
The DWC issues a final, legally binding determination letter to all parties. |
Final Determination |
Important Things to Know About IMR
- Legally Binding: The IMR decision is final and binding on both the injured worker and the insurance company. Judges at the Workers' Compensation Appeals Board (WCAB) cannot overturn an IMR medical decision unless clear administrative error occurred.
- Expedited Reviews: If your treating physician certifies that the denial of treatment poses an imminent and serious threat to your health, an expedited IMR can be completed within 3 to 7 days.
- Re-submission: If your medical condition changes or new medical evidence becomes available, your treating doctor can submit a new treatment request to trigger a new UR and IMR evaluation.
Need Help with IMR? For assistance with your application or questions about an IMR determination, contact an Information and Assistance (I&A) Officer or your legal representative.
