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State of California Health and Human Services Agency Department of Managed Health Care INDEPENDENT MEDICAL REVIEW APPLICATION-English DMC 20-086 New: 01/02 Rev: 09/12 INDEPENDENT MEDICAL REVIEW APPLICATION

How to fill out independent medical review application

How to fill out an independent medical review application:

1. Gather all necessary documentation: Before starting the application, make sure you have all relevant medical records, bills, and correspondence related to the medical treatment being disputed. This will help provide a comprehensive overview of the case.
2. Understand the grounds for review: Familiarize yourself with the specific reasons why you are seeking an independent medical review. Each state may have different criteria, but common grounds include denial of treatment, denial of coverage, or disputed medical necessity. Knowing the grounds will help you provide the necessary supporting documents and arguments.
3. Locate the appropriate application form: Depending on your state, you will have to find the specific independent medical review application form. This can usually be obtained from your state's insurance department or through an online portal. Ensure you have the most up-to-date version of the form.
4. Fill out the application accurately: Take your time to carefully complete the application form. Provide all requested personal information, including your name, contact details, policy number, and any other relevant identification numbers. Be sure to double-check your entries for errors or missing information.
5. Provide a detailed summary of the case: In a designated section of the application, provide a comprehensive summary of your case. Include a detailed explanation of the medical treatment or service in question, the reasons for disputing the denial or decision, and any supporting evidence you have gathered. It is crucial to clearly articulate your arguments and present a convincing case.
6. Include supporting documents: Attach all relevant supporting documents to your application. These can include medical records, bills, test results, doctor's notes, and any correspondence related to the disputed treatment. Ensure that all documents are legible, organized, and clearly labeled to facilitate an easier review process.

Who needs an independent medical review application?

1. Patients: Patients who have had their medical treatment denied or disputed by their insurance provider may need to file an independent medical review application. This ensures that a neutral third party reviews the case and determines whether the treatment was necessary or should be covered by the insurance.
2. Healthcare providers: If a healthcare provider's treatment recommendation or payment claim has been denied by an insurance company, they may choose to file an independent medical review application. This allows for an impartial assessment of the medical necessity and justification of the treatment provided.
3. Insurance policyholders: Individuals who hold health insurance policies have the right to appeal and seek an independent medical review if their insurer denies coverage for a specific treatment. This ensures that their case receives an unbiased evaluation, increasing the chances of favorable outcomes.

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What is independent medical review application?

Independent medical review application is a process in which an independent third party reviews a dispute between a patient and their insurance company regarding the medical necessity of a proposed treatment or service.

Who is required to file independent medical review application?

The patient or their representative is required to file an independent medical review application.

How to fill out independent medical review application?

To fill out an independent medical review application, one must provide all relevant medical records, a letter explaining the reasons for the dispute, and any supporting documentation.

What is the purpose of independent medical review application?

The purpose of an independent medical review application is to resolve disputes between patients and insurance companies regarding the medical necessity of a treatment or service.

What information must be reported on independent medical review application?

The independent medical review application must include relevant medical records, a letter explaining the reasons for the dispute, and any supporting documentation.