How to appeal a health insurance denial in California
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. California lets you ask an independent reviewer to decide, through California Department of Managed Health Care. The deadline to ask: within six months after your health plan sends you a written response to your appeal (DMHC); within 6 months of the insurer upholding its decision (CDI).
Does this apply to you? State external review covers plans regulated by California: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in California
Within six months after your health plan sends you a written response to your appeal (DMHC); within 6 months of the insurer upholding its decision (CDI)
DMHC: an urgent (expedited) IMR is usually decided within 7 days after DMHC receives the supporting documentation; your doctor must document the urgency, and you can go to DMHC right away without waiting out the plan's 30-day grievance process if there is a serious threat to your health. CDI: the review organization must decide within three days of receiving the case information.
Free
State-regulated plans: health plans licensed by DMHC (all HMOs, many PPOs, most Covered California and Medi-Cal managed care plans) and insurance policies regulated by CDI. Self-funded employer plans use the federal process.
California has two regulators: DMHC runs the Independent Medical Review (IMR) for HMOs and most plans (file online at dmhc.ca.gov or mail/fax DMHC 20-224 to 916-255-5241), while the California Department of Insurance runs a separate IMR for PPO and indemnity insurance policies (https://www.insurance.ca.gov/01-consumers/110-health/60-resources/01-imr/, 800-927-4357, also within 6 months of the insurer's final appeal decision). You generally must file a grievance with the plan and wait 30 days (or get a decision) first, except for experimental/investigational denials or a serious threat to health; if one department finds the plan belongs to the other, it forwards the case. Medicare, Medi-Cal fee-for-service and self-funded plans are not eligible.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in California?
Within six months after your health plan sends you a written response to your appeal (DMHC); within 6 months of the insurer upholding its decision (CDI)
Can I get a fast external review in California?
DMHC: an urgent (expedited) IMR is usually decided within 7 days after DMHC receives the supporting documentation; your doctor must document the urgency, and you can go to DMHC right away without waiting out the plan's 30-day grievance process if there is a serious threat to your health. CDI: the review organization must decide within three days of receiving the case information.
Does external review cost anything in California?
Free
Do California’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- DMHC Independent Medical Review (IMR) Application/Complaint Form (DMHC 20-224, Rev. 09/25)
You must apply for an IMR within six months after your health plan sends you a written response to your appeal.
- DMHC: Frequently Asked Questions
If your health problem is urgent, an IMR is usually decided within 7 days after we receive the supporting documentation from you, the doctor, and the health plan.
- California Department of Insurance: Independent Medical Review (IMR) Program
Your request for an IMR must be made within 6 months of the insurance company upholding its decision within the appeals/grievance process.
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.