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Independent Medical Review (IMR)

What is IMR

California's workers' compensation system uses a process called independent medical review (IMR) to resolve disputes about the medical treatment of injured employees. As of July 1, 2013, medical treatment disputes for all dates of injury will be resolved by physicians through an efficient process known as IMR, rather than through the often cumbersome and costly court system.

A request for medical treatment in the workers' compensations system must go through a "utilization review" process to confirm that it is medically necessary before it is approved. If utilization review denies, delays or modifies a treating physician's request for medical treatment because the treatment is not medically necessary, the injured employee can ask for a review of that decision through IMR.

The costs of IMR are paid by employers who are required by law to provide injured employees with all medical treatment that is reasonable and necessary to cure or relieve the effects of a work-related injury. The DWC is required to contract with one or more independent medical review organizations (IMROs) to conduct IMR on its behalf.

The costs of IMR are based upon the nature of the medical treatment dispute and the number of medical professionals needed to resolve the dispute, and are significantly lower than the cost to resolve a dispute through litigation.

For IMR requests submitted on or after April 1, 2014:

  • Standard IMRs involving non-pharmacy-only claims*: $420 per IMR.
  • Expedited IMRs involving non-pharmacy-only claims*: $515 per IMR.
  • Standard IMRs involving pharmacy-only claims**: $390 per IMR.
* IMRs terminated or dismissed before forwarding to a medical professional reviewer: $160 per IMR.
** IMRs terminated or dismissed after forwarding to a medical professional reviewer: $420 per IMR.

IMR program updates

new The IMR Program has prepared a first annual IMR Report that describes the progress made to date and provides an analysis of the data gathered during the first year of the program’s existence.

The Division of Workers Compensation (DWC) and MAXIMUS will be issuing a monthly communication to keep interested parties informed of important program changes as well as general information updates related to the IMR program.

IMR Presentations

Oct. 22, 2014 - Submitting medical records electronically

Jan. 13 and 14, 2014 - DWC educational forum on UR and IMR

Dec. 18, 2013 – Injured Worker / Applicant Attorney

Nov. 5, 2013 – Claims Administrators

Keys to a successful IMR

It is the claims administrator's responsibility to:

  • Send the injured worker a copy of the utilization review (UR) decision letter on a request for treatment, and, if applicable, the supporting recommendation by a utilization review organization
  • Send the completed IMR application form (DWC IMR-1 form) to the injured worker if the UR decision delays, denies or modifies the request for treatment
  • Make sure the IMR application form is the correct DWC IMR-1 form (not MPN-IMR form, not a modified or self-created form)
  • Clearly indicate type of review on the application, either expedited (EXP) or regular (REG). Expedited reviews must be accompanied by a physician statement of necessity or the UR must have been conducted in an expedited manner
  • Include the WCIS number (also known as the JCN)
  • Indicate whether liability is being disputed on the application. If liability is disputed, IMR is not available until the liability issue has been resolved. For claims that are under investigation and for which liability has not yet been denied, IMR is available within the first 90 days after the claim is presented, for medical treatment costs up to $10,000.

If you are an injured worker or the designee, before you submit a request for IMR, it is very important do the following:

  • Include a copy of the complete utilization review (UR) determination with the IMR application form that was provided to you by your claims adjustor
  • Sign the IMR application form before submitting a request for IMR
  • Send the signed IMR application and the UR determination within 30 days of receiving the UR determination to the address on the form.

As of July 1, 2013, all dates of injury are eligible for IMR.

Application process

The injured worker, or someone she or he designates may request IMR. If utilization review denies, delays, or modifies a requested medical treatment for an accepted claim, the claims administrator must send the injured worker a notice of denial along with a partially completed IMR request form.

To request IMR, the worker must submit an application for IMR and mail the following information within 30 days of receiving the utilization denial to the address below:

  • Original signed Application for Independent Medical Review
  • A copy of the utilization review denial of treatment

Mail the above information to:

DWC - IMR
c/o Maximus Federal Services, Inc.
PO Box 138009
Sacramento, CA 95813-8009

If you did not receive or have misplaced the IMR application form, you may contact the claims administrator for another copy.

For questions regarding your IMR request, please contact your employer's insurance company claims administrator.

Resources

Contact Maximus

For those interested in becoming an IMR reviewer, please contact Maximus at:
Kimberly D. Donselaar, CPCS
Director, Professional Relations
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 700
Pittsford, New York 14534
Office: (585) 348-3109
Fax: (585) 869-3390
Email: KimDonselaar@maximus.com
For additional questions or assistance, please contact Maximus at:
Toll free: 1-855-865-8873
Fax: (916) 605-4270
Email: IMRhelp@maximus.com

Contact DWC Medical Unit

For other questions related to the IMR process not addressed above, please contact the DWC Medical Unit:
DWC - Medical Unit
Independent Medical Review
P.O. Box 71010
Oakland, CA 94612
Toll free: 1-800-794-6900
Phone: (510) 286-3700
Email: DWC@dir.ca.gov

What's New

December 2014