What Happens When Maximus Accepts Your IMR Appeal in California Workers’ Compensation — and Exactly What to Send

Professional thumbnail showing scales of justice, a stethoscope, and medical documents with barcode for Maximus IMR appeal guide in California workers’ compensation

When a utilization review (UR) company denies your treating doctor’s request for surgery, medication, a specialist referral, or other medical treatment, the next critical step for many injured workers in California is Independent Medical Review (IMR). You file the appeal, and then Maximus — the organization that administers IMR for the state — notifies you that it has accepted the appeal and is requesting additional information.

This moment is time-sensitive and strategically important. Understanding precisely what Maximus expects, what the claims adjuster is required to send, and what you can (and should) submit can make the difference between an overturned denial and a year-long barrier to treatment.

This guide walks through the process in clear, practical detail so injured workers, their families, and advocates know exactly what to do when that notice of assignment and request for information arrives.

The Sequence of Events Leading to Maximus’s Request

Most injured workers reach this stage after a familiar pattern:

1. The treating physician submits a Request for Authorization (RFA) for treatment.
2. The utilization review organization issues a denial (or modification).
3. The injured worker timely files an IMR application.
4. Maximus accepts the appeal and issues a Notice of Assignment and Request for Information.

That notice is sent to both the injured worker (or their representative) and the claims adjuster. It triggers a short response window — currently approximately 15 days — during which supporting medical records must be submitted. Missing this window or sending incomplete documentation can weaken an otherwise strong case.

The Claims Adjuster’s Mandatory Submission

California law requires the claims administrator to send Maximus all medical reports from the preceding six months. This obligation exists even though the appeal belongs to the injured worker. Maximus wants a current picture of the medical situation, so the six-month rule focuses on recent treatment notes, diagnostic studies, and progress reports.

If the injured worker has been treating for fewer than six months, the adjuster will typically send everything available. The adjuster’s packet forms the baseline record set that the IMR physician reviewer will examine.

Your Opportunity: Submitting Supporting Records Beyond the Six-Month Window

Here is the practical advantage many injured workers overlook: you are not limited to the last six months. You may submit any records that support the medical necessity of the requested treatment, including documents older than six months.

Common high-value items include:

• A Qualified Medical Evaluator (QME) report from a year earlier that specifically recommended the surgery or treatment now under review.
• Earlier treating physician reports that documented the same need.
• Prior authorizations issued by the carrier when the condition was previously deemed medically necessary.
• MRI, CT, or other diagnostic studies that clearly show the pathology (for example, a torn ACL) even if the imaging is eight or more months old.
• Specialist consultation notes recommending urgent intervention.

These older records often provide crucial context. A QME who stated that the injured worker “needs ACL reconstruction and will not return to work without it,” combined with imaging confirming the tear and a surgeon’s recommendation, can powerfully support an appeal even if those documents fall outside the adjuster’s six-month window.

How to Package and Submit Your Records Correctly

Maximus’s request packet includes a cover page with a distinctive barcode. Place that barcode page on top of everything you send. The barcode links your submission to the correct case file.

You may transmit the materials by mail or fax. Many practitioners also send a simultaneous copy to the claims adjuster for transparency and to create a clear record of what was provided.

Best practice is to include a simple cover letter or proof of service that itemizes every document:

• Maximus Notice of Assignment and Request for Information dated [date]
• QME report of Dr. [Name] dated [date]
• MRI study dated [date]
• Treating physician report dated [date]
• Prior authorization letter dated [date]
• Any additional supporting records

Itemizing the packet eliminates confusion about what Maximus actually received and creates a clear paper trail if questions arise later.

Timeline After You Submit

Once Maximus receives the complete set of records (from both the adjuster and the injured worker), the IMR physician reviewer evaluates the medical necessity of the requested treatment under the applicable Medical Treatment Utilization Schedule (MTUS) and evidence-based guidelines.

Decisions typically issue within two to four weeks after the record submission deadline, though the exact timing can vary with caseload. The outcome will be one of two results:

• Overturn — Maximus finds the treatment medically necessary. The claims administrator must authorize it.
• Uphold — Maximus affirms the original denial. In most cases that upheld denial remains effective for up to one year. The carrier can rely on it for subsequent requests for the same treatment during that period.

There are narrow exceptions (for example, if Maximus failed to consider material submitted records, or in rare cases involving fraud or significant new medical developments), but these are uncommon. Most upheld denials stand for the full year.

Why Older Records Matter Strategically

Utilization review often focuses heavily on the most recent notes. A treating physician’s current RFA may be brief, or the patient may have experienced delays (pregnancy, MPN disputes, scheduling issues, or other interruptions). Older records can fill critical gaps:

• They demonstrate consistency of medical opinion over time.
• They show that the carrier itself previously authorized the same treatment.
• They provide objective diagnostic evidence that may not have been repeated recently.
• They counteract any suggestion that the condition has resolved or that treatment is no longer indicated.

Sending only the recent six months of records leaves the IMR reviewer with an incomplete story. Adding the earlier QME, imaging, and prior authorization creates a fuller, more persuasive medical narrative.

Practical Tips for a Strong Submission

• Act immediately upon receiving the Maximus notice. Fifteen days is short once you account for gathering records, preparing the cover sheet, and transmission time.
• Obtain complete copies of older reports from your treating physicians, QME, or prior counsel if necessary.
• Keep your own organized file of every document sent to Maximus and to the adjuster.
• If you are represented, coordinate closely with your attorney so that nothing is duplicated or omitted.
• Do not assume the adjuster’s six-month packet will include everything favorable to you. It is your responsibility to supply supporting older material.

Related Pathways When IMR Does Not Succeed

An upheld IMR denial is frustrating, but it is not always the final word on medical care. Other mechanisms exist in California workers’ compensation for addressing treatment disputes, though they require additional legal and medical effort. These alternatives are beyond the scope of this article and are best discussed with an experienced workers’ compensation attorney familiar with your specific case facts.

Summary: What You Must Do When Maximus Accepts the Appeal

1. Note the 15-day (approximate) deadline the moment the Notice of Assignment and Request for Information arrives.
2. Understand that the claims adjuster will send the last six months of records.
3. Gather and submit any supporting documents older than six months that demonstrate medical necessity — QME reports, prior authorizations, diagnostic studies, and earlier treating physician recommendations.
4. Place Maximus’s barcode cover page on top of your packet.
5. Itemize every document in a cover letter or proof of service.
6. Send the packet by mail or fax (and ideally copy the adjuster).
7. Wait for the IMR decision, which typically arrives within a few weeks after the record deadline.

Following these steps gives the independent medical reviewer the fullest possible picture of why the requested treatment is medically necessary. In many cases, that complete record set is what converts a denial into an authorization.

Injured workers who move quickly, organize their supporting evidence carefully, and supply relevant older records place themselves in the strongest position when Maximus reviews the appeal. The process is technical and deadline-driven, but the opportunity to influence the outcome is real — and it begins the moment that notice of assignment arrives.

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