Independent Medical Review (IMR) Glossary of Terms
Administrative Director of the Division of Workers' Compensation: Official given the responsibility to contract with an Independent Medical Review Organization (IMRO) to conduct reviews and to determine whether an IMR application is eligible for review and assign IMR applications to the IMRO.
Claims administrator: An insurer, self-administered self-insured employer, or third- party administrator responsible for adjusting workers’ compensation claims. A claims administrator is obligated to perform UR on medical treatment recommendations, issue UR decisions, and compensate providers for treatment costs. “Claims administrator” includes a utilization review organization (URO) contracted by the claims administrator to specifically conduct UR. Also called claims examiner or claims adjuster.
Conditionally non-certified (CNC) decision: A UR decision that has been denied because the treating physician has not provided the medical information requested by the claims administrator that is required to make a medical necessity determination on the treatment recommendation.
Disputed treatment: Treatment requested through UR that has been modified or denied in a UR decision and subsequently submitted for IMR.
FDL (Final determination letter): Letter issued by the IMRO communicating the IMR decision(s) in layperson’s terms, sent to the worker or representative, the physician who requested the treatment, and to the liable employer or insurer. The FDL is issued by the Administrative Director and subject to appeal before the Workers’ Compensation Appeals Board.
IMR (Independent Medical Review): Process through which an injured worker, either directly or through a representative or agent, may dispute a UR decision that either denies or modifies a medical treatment recommendation made by the injured worker’s primary treating physician. IMR is conducted by the IMRO under contract with the Administrative Director.
IMR application: The application form (DWC Form IMR) used to request IMR. The application form must be completed by the claims administrator, except for the signature of the employee, and included with a copy of the UR decision that denies or modifies a medical treatment recommendation. A complete IMR application must be signed and include a copy of the disputed UR decision.
IMR decision: Decision of the IMRO (deemed the decision of the DWC administrative director), made on the basis of medical necessity, regarding a single disputed treatment. An IMR decision is communicated in an FDL, which may contain multiple treatment decisions.
IMRO (Independent Medical Review Organization): Organization under contract with the Administrative Director to conduct IMR of eligible cases.
MTUS (Medical Treatment Utilization Schedule): Evidence-based standards of medical care adopted by the Division of Workers' Compensation, to be used as treatment guidelines in the California workers’ compensation system. Treating physicians, UR reviewers, and IMR physician reviewers are required to use it, when relevant, as the basis of treatment, UR decisions, and IMR decisions. The MTUS is presumed to be correct and is rebuttable with a preponderance of the scientific/medical evidence.
Physician reviewer: Licensed medical professional designated by the IMRO to render an IMR decision on the basis of medical necessity regarding a disputed treatment.
Primary treating physician: Physician who is primarily responsible for managing the care of an injured worker.
Treatment request: Request for authorization (i.e., compensation for) of medical treatment submitted by the treating physician to the UR claims administrator on a request for authorization form (DWC Form RFA).
UR (Utilization review): Process used by a claims administrator to approve, modify, or deny a medical treatment request made by the injured worker’s treating physician. UR begins upon the submission of a complete request for authorization (Form RFA) by the physician.
Utilization review (UR): The process used by insurance companies to decide whether to authorize and pay for treatment recommended by a treating physician.
UR decision: Decision by the claims administrator to approve, modify, or deny a medical treatment request made by the injured worker’s treating physician. Only a physician may modify or deny a medical treatment request. Unless the decision is based on the treating physician’s failure to provide requested information, the UR decision is required to be based on medical evidence (see MTUS).