Final Regulations Set for the IMR Process

By Adam Dombchik, Esq.

Senate Bill 863 which was enacted into law as of January 1, 2013 created an Independent Medical Review (IMR) procedure to resolve utilization review (UR) disputes regarding medical treatment recommendations for injured workers.

The Office of Administrative Law (OAL) for the State of California approved the final regulations (rules) for the IMR process on February 12, 2014.  Here are some of the important points you need to know regarding these updated, final rules:

1.  As of March 1, 2014 a new IMR application form must be used to appeal a denial of medical treatment.  It remains the insurance company's obligation to completely fill out the IMR application, and it is required to be sent to the injured worker and his or her attorney, along with a copy of any UR denial of medical treatment.

2.  The IMR process still has strict timelines and requirements, and gives an employee only 30 days from the date of a UR determination to request an IMR of the decision.

3. The new rules make it clear that an IMR determination cannot be based solely on information provided by and within a UR determination.  (Click here for an example of this form.

4. The regulations include a new Request for Authorization (RFA) form that physicians are required to use when submitting requests for medical treatment.  (Click here for an example of this form.)

5.  Documentation substantiating the need for the requested treatment must be attached to the RFA.  The RFA instructions specifically state "reference to specific guidelines used to support treatment should also be included." 

6.  Regulation 9792.10.1(b)(1) requires that the IMR application "must be submitted with a copy of the written decision delaying, denying, or modifying the request for authorization of medical treatment."  This is a requirement that a copy of UR denial letter be submitted with the IMR application. 

7.  Regulation 9792.10.1(b) allows a physician to apply for an internal UR appeal process to resolve disputes regarding a UR determination, but the timelines for this internal UR process could present problems.  Under this regulation, a request for an internal UR appeal by either the worker or the treating physician must be submitted within 15 days of receipt of the UR denial.  The rule goes on to require completion of the internal UR process within 30 days of receipt of the request.  Together these two provisions permit a determination in the internal UR process to be issued as late as 45 days after receipt of the UR denial.  However, initiation of this internal UR process does not toll the 30-day deadline for filing an IMR appeal.  As such, these processes will likely run at the same time and an injured worker or his or her attorney or physician should not delay filing an IMR application while the internal UR appeal process is pending. 

8.  The claims administrator is required to send the last six months of relevant records to IMR within 15 days of Notice of Assignment; the employee or his or her representative  may also send records within 15 days. The 15-day time limit runs concurrently for all parties.

Although the rules are now final for this IMR process, there remains further discussion throughout the state that the rules could be further updated throughout the course of this year and next.  The attorneys at Gordon, Edelstein, Krepack, Grant, Felton & Goldstein, LLP make it a priority to stay updated with respect to changes in the law that would affect the people we represent.  In return, we will continue to update you regarding any changes in the workers compensation system.