How to appeal a health insurance denial in California

1. 1

   File a grievance with your health plan

   This is your plan's own appeal process, and it normally comes first.

   You cannot be required to stay in it for more than 30 days — or more than three days if your case qualifies for expedited review.

   Health & Safety Code § 1374.30(d)(3)

2. 2

   Apply to the DMHC for Independent Medical Review

   Once the plan upholds the denial, or those days have passed without resolution, you can apply to the Department of Managed Health Care.

   Where there is an imminent and serious threat to your health, documents go to the review organisation within 24 hours, and the Department may waive step 1 entirely in extraordinary and compelling cases.

   § 1374.31(a)

3. 3

   An independent physician reviews it

   Not your plan, and not the Department either.

   The Department contracts with review organisations that must be independent of any health plan doing business in California, under conflict-of-interest standards.

   § 1374.32(a)

4. 4

   If the denial is overturned, the plan must act

   The decision binds your plan; it is not advisory.

   The plan must authorise the service within five working days of the written decision — sooner if your condition warrants — or reimburse you within five working days where the care has already been given.

   § 1374.34(a)

This is the part no plan or advice site can tell you: the state publishes every one of these decisions, and we have classified 42,621 of them. Across 2021-2025, reviewers did not sustain the plan’s denial in 65.2% of cases — but that average hides an enormous range.

• Pharmacy74.6%n=4,121
• Mental Health79.8%n=1,558
• Diagnostic imaging & screening47.8%n=1,248
• Pain Management79.5%n=937
• Durable medical equipment56.0%n=679
• Cancer Care52.6%n=485

All treatment classes · by condition · the full findings, 12% to 98%

Independent Medical Review is California’s process for plans the state regulates. If yours is a self-funded employer plan — roughly half of Americans with employer coverage — your appeal goes to a federal process instead, and the insurer’s name on your card is often just the administrator. Medicare and Medicaid have their own separate systems. Which one covers you · what your state publishes.