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What Really Happens in a Medical Assessment? A Step-by-Step Walkthrough

Written by Sample HubSpot User | Feb 3, 2026 12:00:37 AM

A medical assessment (often called an Independent Medical Examination, or IME) is a structured, impartial process designed to answer specific clinical questions in the context of a claim.

At Medylex, our role is to help our partners get the right medical opinion, on the right timeline - without unnecessary administrative friction - while ensuring the assessment experience is clear and respectful for the examinee.

Here’s what the process looks like, from referral to final report.


Step 1: Referral & intake

The process begins when a referral source submits a request for an assessment. The referral outlines:
- the purpose of the assessment (what decisions the opinion will inform),
- the medical specialty required, and
- any timeline considerations.

From there, our intake team confirms the key questions being asked and gathers the relevant file materials needed to proceed. If anything is missing, we’ll coordinate with the referral source to obtain it upfront - so the assessor has what they need and the appointment can move forward without delays.



Step 2: Scheduling & coordination

Once the file is complete, an intake coordinator schedules the assessment based on the requested timeframe and availability. Throughout scheduling, we focus on clear communication and a smooth process - because the faster the assessment is booked properly, the faster the file can move.



Step 3: Pre-assessment record review

Before the appointment, the assessor reviews the records provided to understand the individual’s medical history and the context of the claim. This pre-review is essential: it ensures the assessor comes prepared, can ask more focused questions, and can complete a thorough examination aligned to the specific questions being asked.



Step 4: Day-of assessment, consent, and expectations

On the day of the assessment, the examinee attends as scheduled and reviews a consent form. This form explains:

- the purpose of the assessment,
- how the information will be used, and
- that participation is voluntary and documented appropriately.

This step helps set expectations and supports transparency before the clinical portion begins.



Step 5: The assessment

The assessment itself typically includes a focused interview and an objective examination, directed strictly by the referral questions.

Importantly, the assessor does not provide treatment or medical advice. The purpose is to evaluate and provide an independent opinion - not to replace the examinee’s treating providers.



Step 6: Clinical analysis & opinion development

Following the examination, the assessor analyzes the clinical findings in the context of the records reviewed. Medylex facilitates independent medical assessments grounded in clinical integrity, operational clarity, and respect for all parties. We do not advocate for either side; assessors are carefully matched to the clinical question and supported by complete records, clear intake processes, and defined timelines. Opinions are evidence-based, limited to the referral questions, and delivered in clear, professionally reviewed reports designed to support confident, defensible decision-making.



Step 7: Report writing & quality review

A report is then prepared summarizing key findings and medical opinions. Before delivery, the report goes through a quality check to ensure it is:

- clear and easy to follow,
- complete and responsive to the referral questions, and
- accurate and professionally presented.



Step 8: Delivery within agreed timelines

Once finalized, the report is delivered to the requesting client within the agreed timeline - so next steps can be taken with confidence.

Get in touch with the Medylex team to book an assessment. 

 

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