Independent Medical Review: Disputes Re Utilization Review Determinations
Under SB 863, Treatment Request Disputes Are Resolved by Independent Medical Review (IMR) When Utilization Review (UR) denies, delays or modifies a Request for Authorization for Treatment, UR must include a form (not to exceed two pages) advising the injured worker of his/her rights for Independent Medical Review. See Cal Lab Code 4610.5 for details on form.
After the decision by made by UR, IMR must be requested by the injured worker no later than 35 days of the UR determination. IMR can be deferred if the employer disputes liability for treatment at the time of the UR decision for any reason except medical necessity. Once IMR is assigned, the employer has 10 days to provide medical information including the injured worker's submitted information, and also to serve the injured worker all documents served to IMR.
IMR review is limited to medical necessity. Furthermore, IMR must issue a decision within 30 days (3 days if serious threat to health) from the date of the IMR request. The decision of IMR is generally binding for one year unless there are new circumstances which warrant a new Request for Authorization by the primary treating physician which would then be subject to another Utilization Review. IMR appeals can be made within 30 days if there is clear and convincing evidence that IMR acted without power, there is evidence of fraud, IMR doctor has financial conflict of interest, the decision is biased, or there is a plain erroneous finding of fact based on ordinary knowledge. If the appeal is granted, then the request is assigned to another IMR reviewer.
If IMR approves treatment, the employer/insurance carrier has 20 days to reimburse or 5 days to authorize treatment. Penalty for failure to comply can be up to $5,000.