1. DWC

Answers to frequently asked questions about Independent Medical Review (IMR)

Topics covered in this FAQ include:

The basics
Cost of IMR
IMR request
Ineligibility
IMR process
Appeal process

About the basics

What is independent medical review?

Independent medical review (IMR) is a quick, non-judicial way to resolve disputes about the medical treatment of injured employees. If a request by a treating physician for a specific course of medical treatment is denied or modified by a claims administrator for the reason that the treatment is not medically necessary, the injured employee can ask for a review of that decision by physician-conducted IMR.

What is a medical necessity treatment dispute?

A medical necessity treatment dispute is a request by a treating physician for a specific course of medical treatment that has been modified or denied by a utilization review (UR).

Who performs IMR?

The administrative director (AD) has designated Maximus as the independent medical review organization to conduct all IMR. Maximus contracts with medical professionals to perform IMR, and each medical professional must meet rigorous qualification and conflict of interest standards.

When did IMR become effective?

IMR became available as of July 1, 2013 to resolve medical necessity treatment disputes for all dates of industrial injury.

How do I become an IMR reviewer?

For those interested in becoming an IMR reviewer, please contact Maximus by email at Professionalrelations@maximus.com.

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About the cost of IMR

What does IMR cost and who pays for IMR?

There are costs for IMR and the claims administrator is required to pay those costs. The initial cost structure for IMR is based upon the nature of the dispute and the number of medical reviewers, and relies on experiential data from which DWC and its independent medical review organization (IMRO) were able to estimate the anticipated volume of disputes. The costs for IMR are significantly lower than the cost to resolve a dispute through litigation.

For IMR requests submitted on or after Jan. 1, 2020:

• Standard IMRs involving pharmacy and non-pharmacy claims*: $345 per IMR.
• Expedited IMRs involving pharmacy and non-pharmacy claims*: $345 per IMR.
• IMRs terminated or dismissed before forwarding to a medical professional reviewer: $115 per IMR.
• IMRs terminated or dismissed after forwarding to a medical professional reviewer: $345 per IMR.

*A “non-pharmacy” IMR is an IMR where not all treatments in dispute fall under the service category “pharmaceuticals.”

** A “pharmacy” IMR is an IMR where all treatments in dispute fall under the service category “pharmaceuticals.”

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About the IMR request

Who can request IMR?

Only the injured employee or his or her designee can request IMR.

• If the injured employee is represented, the employee’s representative or attorney can request IMR.
• If the injured employee is unrepresented, he or she can designate a parent, guardian, conservator, relative or other person as an agent to act on his or her behalf to request IMR.
• The physician whose request for authorization of medical treatment was denied or modified may join with or assist the injured employee in seeking IMR.
• If the injured employee required emergent medical treatment because of an imminent and serious threat to his or her health, the provider of emergency medical treatment can submit an application for IMR.

How is IMR requested?

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

• Original signed Application for Independent Medical Review (DWC Form IMR)
• 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

The claims administrator is required to enclose the DWC form IMR-1 with the UR decision notifying the injured employee that the requested treatment was denied or modified. If you did not receive or have misplaced the IMR request form, you may contact the claims administrator for another copy.

To request an expedited IMR, the DWC form IMR-1 must include the treating physician’s certification that the employee faces an imminent and serious threat to his or her health.

Is there a deadline to request IMR?

Yes. IMR must be requested within 30 days of the date of service of the UR decision. A copy of the IMR application must be sent to the claims administrator.

If the request for IMR is made by a provider of emergency medical treatment, the deadline for filing the application for IMR is within 30 days after the service of the UR decision concerning the provider’s retrospective request for authorization of the emergency medical treatment.

If at the time of the UR decision the claims administrator is also disputing liability for the treatment for any reason besides medical necessity, the request for IMR is extended to 30 days after service of a notice to the employee showing that the other dispute of liability has been resolved.

What happens after IMR is requested?

The AD uses the following criteria to review the DWC form IMR-1 and determine whether the dispute is eligible for IMR:

• Is the form timely and complete? (Including a signature and a copy of the UR decision)
• Has there been a prior request for IMR of the disputed treatment?
• Does the claims administrator dispute liability for an occupational injury or a claimed injury to any part or parts of the body?
• If further information is needed to determine that a disputed medical treatment request is eligible for IMR, parties must provide that information within 15 days of receipt of request.

What happens if the AD determines a dispute is not eligible?

• Please see the section below titled About ineligibility.

What happens after the AD determines the dispute is eligible for IMR?

Within one business day of the AD’s finding that a dispute is eligible for IMR, Maximus must notify the parties in writing that the dispute has been assigned for review and whether the review will be “regular” or “expedited.”

For a regular review:

• The required documentation must be provided to Maximus within 15 calendar days of the date designated on the mailed notification or within 12 calendar days of an electronic notification.

For an expedited review:

• The required documents must be provided to Maximus within 24 hours following receipt of the notification.

Notification must include name and address of Maximus, must identify the medical treatment dispute and must indicate the date the DWC form IMR-1 was received by Maximus.

How do I terminate a request for IMR?

An IMR can be terminated by a written request to Maximus stating that one of the following circumstances has occurred:

• The treatments in dispute were authorized; 
• The underlying workers’ compensation case was settled by compromise and release; 
• A material change in circumstance renders the IMR moot (e.g. a new treating physician with different course of treatment); or 
• The injured worker wishes to withdraw the request for IMR. (Only the injured worker or his/her appointed representative can request a termination by withdrawal.)

The written documentation must include a statement that the other party has been notified of the reason for the IMR termination. Currently, parties can send requests for termination to MAXIMUS by any of the following means:

1. Facsimile to (916) 605-4270;
   
2. U.S. Postal Service mail; or
   
3. Delivery Service

UR found the recommended treatment to be medically necessary.  However, the claims administrator is disputing liability for the injured body part that needs treatment.  Can IMR be postponed, or deferred, until a decision is made that the body part is covered?

Yes. If, at the time of the UR decision, the claims administrator disputes their liability for the claim, affected body part, or the treatment itself on grounds other than the medical necessity of the treatment, then IMR will be postponed, or deferred, until the issue is resolved (either through agreement or by a decision from the WCAB). Liability disputes include claims that are denied; disputes over treatment for body parts that have not been accepted as work-related, or the application of laws that limit treatment  (for example, the 24-visit cap on chiropractic treatment). 

IMR will be deferred only if the liability dispute existed at the time of the UR decision.  Generally, this will be reflected on the IMR application: the claims administrator will check the box on the form which asks if a liability dispute exists and will provide the reason for the dispute. Upon review of the application and confirmation that the box has been checked and such a dispute exists, DWC will issue a determination finding the IMR application to be ineligible for review. The parties should resolve their dispute prior to submitting the same medical treatment request for UR. If there is no indication that a liability dispute existed at the time of the UR decision, then the application will be found eligible and the UR decision will be subject to IMR.

The claim was denied after the UR decision denying the recommended treatment issued and after the IMR application was filed.  Can IMR still be postponed or deferred?

No. If there is no indication that a liability dispute existed at the time of the UR decision denying or modifying the medical treatment - if the liability dispute box on the IMR application was not checked, for example - then IMR will proceed to a final determination. This process will not be postponed, deferred, or otherwise stopped regardless of whether the claims administrator denies the claims, or raises any other liability dispute, after the IMR application is filed. (Of course, the IMR can be stopped if the treatment is authorized by the claims administrator.)

However, if a liability dispute does comes up after the IMR application is filed, the claims administrator may postpone, or defer, the implementation of the final IMR determination decision by Maximus until after the matter of liability is resolved (either through agreement or by a decision from the WCAB). Such a deferral must be raised promptly by the claims administrator, or it may be subject to the assessment of administrative penalties.

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About ineligibility

I filed an application for IMR, and now have received a decision from the AD telling me my application is ineligible for review. Why?

IMR is available to an injured worker when a medical treatment request by their treating physician is either denied or modified by a claims administrator for the reason that the treatment is not medically necessary. (The review process of the treatment request by the claims administrator is called “utilization review” or UR.) To request IMR, the injured worker, or their designated representative, must:

1. sign the DWC form IMR-1 that was included with the written UR decision that denied or modified the treatment request;
2. attach a copy of the written UR decision;
3. timely mail or fax the signed application and the copy of the written UR decision to the designated IMRO that will conduct IMR; and
4. mail a copy of the IMR application to the claims administrator. IMR of the claims administrator's decision will be conducted if the application was properly filed and the only dispute involves the medical necessity of the requested treatment.

There is nothing you can do to correct an IMR application that has been untimely filed. If your claims administrator has disputed liability for your work injury, or a claimed injury to any part or parts of the body, then that dispute must be resolved before IMR can proceed. If your ineligibility determination was based on your physician's failure to respond to the claims administrator's request for additional information regarding the proposed medical treatment, you should immediately talk with your physician to make sure that the missing information is sent to the claims administrator for review.

I did respond to the Medical Unit's request. Why did l still receive an ineligibility determination saying that I didn't submit a copy of the written UR determination?

If you did, in fact, timely submit a copy of the written UR decision to Maximus Federal Services, Inc., please contact them directly and be ready to provide any documents or proof you have showing that the copy was timely sent in.

Can I challenge the decision of the Administrative Director?

Yes. If you believe the ineligibility finding by the AD is wrong, you can file a petition with the Workers' Compensation Appeals Board no later than 30 days after the date the AD's decision was mailed to you. The requirements for the petition can be found at California Code of Regulations, title 8, section 10957.1.

Where can I get additional help to file a petition?

Information on how to file an appeal can be obtained from the DWC's Information and Assistance Unit. Contact information can be obtained by calling (800) 736-7401 or finding the number of a local I&A office from a local phone book under State of California, Industrial Relations Department. The telephone number and address of a local Information & Assistance Unit office can also be found on the Division's website at: http://www.dir.ca.gov/dwc/IandA.html.

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About the IMR process

What documents must the claims administrator provide to Maximus?

Within the time periods for regular or expedited review, the claims administrator must provide the following to Maximus, as well as to the employee and the employee’s provider (unless previously provided to the latter in which case only a list need be provided):

• All treating physician reports regarding the employee within six months prior to the date of request for authorization.
• All reports and records of the employee’s medical treatment that are identified in the request for authorization or in the UR determination.
• A copy of the UR determination notifying the employee and the employee’s treating physician that the requested medical treatment was denied, delayed or modified.
• A copy of all information provided to the employee by the claims administrator concerning the UR decision regarding the disputed treatment.
• A copy of any materials the employee or the employee’s medical provider submitted to the claims administrator in support of the request for authorization of the disputed treatment.
• A copy of any other relevant documents or information, including statements by the claims administrator explaining the reasons for the decision to deny, modify or delay the requested treatment.

What if there is newly discovered information?

After submission of the required documents, if the claims administrator has newly developed or discovered medical records that are relevant to the dispute, any such records shall be immediately sent to Maximus concurrently with a copy to the employee or the employee’s provider.

Can the employee or the employee’s designee submit documents to Maximus?

Yes. Within the time periods for regular or expedited review, the employee or designee may provide the following documents to Maximus concurrently with a copy to the claims administrator (unless previously provided to the latter, in which case a list of the documents is provided):

• The treating physician’s recommendation indicating the disputed medical treatment is medically necessary for the employee’s medical condition.
• Medical information or justification that a disputed medical treatment, on an urgent or emergency basis, was medically necessary for the employee’s medical condition.
• Information supporting the employee’s position that the disputed medical treatment is or was medically necessary.
• Any newly developed or discovered relevant medical records.

Can Maximus request additional information from the parties?

Yes. The party to whom the request for additional information is directed must send the requested information to Maximus with concurrent service on all other parties within five business days of a regular review or within one calendar day of an expedited review.

How is the review conducted?

When the AD advises Maximus that a dispute is eligible for IMR, Maximus designates a medical reviewer to conduct the IMR. The AD may authorize Maximus to utilize more than one medical reviewer where the employee’s condition and the disputed treatment are sufficiently complex that one reviewer could not reasonably address all disputed issues.

• The medical reviewer does not conduct a physical examination of the employee.
• The medical reviewer conducts a review of the documents submitted by the parties and issues a written determination that states whether or not the disputed medical treatment is medically necessary.
• The determination includes the employee’s medical condition, a statement regarding the disputed medical treatment, references to the specific scientific and medical evidence applied and the clinical reasons regarding medical necessity.
• The determination must be written in clear language.
• If two or more medical reviewers reviewed the case, each shall issue a written determination.
• The recommendation of the majority of medical reviewers shall prevail. In the event of a tie, the determination shall be in favor of providing the disputed treatment.
• Maximus provides the AD, the employee, the employee’s provider and the claims administrator with the final determination of the medical reviewer along with a description of the qualifications of the medical reviewer(s).
• Maximus must keep the names of the medical reviewer or reviewers confidential in all communications with outside entities or individuals.

What are the time frames for final IMR determination?

For a regular review:

• Within 30 days of receipt of DWC form IMR-1 and the supporting documentation.

For an expedited review:

• If the disputed treatment has not been provided, within three days of receipt of DWC form IMR-1 and the supporting documentation
• If disputed treatment has been provided, within 30 days of receipt of DWC form IMR-1 and the supporting documentation.

The AD may extend deadlines for regular and expedited review for up to three days in extraordinary circumstances or for good cause.

What is the effect of the decision issued by Maximus?

• The decision issued by Maximus is deemed to be the determination of the AD and it is binding on all parties.
  
• If the disputed treatment is determined to be medically necessary, the claims administrator must promptly implement the decision unless it disputed liability for the treatment on a basis other than medical necessity or it files an appeal.
  
• If the disputed treatment has already been provided, the claims administrator must reimburse the medical provider within 20 days.

If the disputed treatment has not been provided, the claims administrator must authorize the treatment within five business days.

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About the appeal process

Can an IMR determination be appealed?

Yes, by filing a petition with the Workers’ Compensation Appeals Board (WCAB) within 30 days of the mailing of the final determination.

The final determination is presumed correct and the WCAB cannot make a finding of medical necessity contrary to the final determination.

The following are the grounds for appeal and the standard is clear and convincing evidence that:

• The AD acted without or in excess of her powers
• The final determination was procured by fraud
• The medical reviewer was subject to a material conflict of interest
• The final determination was the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color or disability
• The final determination was the result of a plainly erroneous mistake of fact.

What happens if the WCAB reverses the final determination?

The WCAB returns the dispute to the AD for one of the following actions:

• Assignment to a different IMRO
• Assignment to a different medical reviewer where a different IMRO is not available.

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October 2023