During an independent medical review (also referred to as an “external review”), an independent third party reviews your insurer’s decision.[3] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under California law, you are entitled to request an independent medical review in the following circumstances:

  • You filed an internal appeal but your insurer failed to provide you with a decision within the allotted timeframe; or
  • Your insurer denied your claim after you filed an internal appeal because it determined that your requested treatment was medically unnecessary, experimental, or investigational.[4]

You can request an expedited independent medical review at the same time that you request an expedited internal appeal in urgent situations.[5]