Insurance & Medical Bills · Health coverage and bills
Health plan denials, appeals and Independent Medical Review
In this guide
- Most California health plans are regulated by the DMHC; some insurance policies by the Department of Insurance.
- A grievance usually goes to the plan first, and the plan generally has 30 days to respond (faster in urgent cases).
- Independent Medical Review is free and its decisions bind the plan.
Who regulates the plan
- Department of Managed Health Care (DMHC): HMOs, most PPO plans, and Medi-Cal managed care plans.
- Department of Insurance (CDI): some PPO and other health insurance policies.
- Federal agencies: many large employer self-funded plans (U.S. Department of Labor) and Medicare (Centers for Medicare & Medicaid Services).
A member card or plan documents usually show which applies. The DMHC Help Center can also tell callers where to go.
How appeals generally work
- Grievance with the plan. The member files a grievance or appeal with the health plan, often with a doctor’s supporting letter.
- Plan decision. The plan generally must decide within 30 days, or within 72 hours in urgent cases.
- State review. If the plan denies or doesn’t respond in time, the member can ask the DMHC or CDI for an Independent Medical Review or file a complaint.
Independent Medical Review
An IMR is available when a plan denies, changes, or delays care as not medically necessary, experimental, or investigational, or denies emergency care payment. Independent doctors review the case. There is no cost, and a favorable decision requires the plan to cover the care.
Time frames (DMHC)
- Plan grievance decision: generally 30 days; urgent: 72 hours
- IMR decision: generally 45 days, faster for urgent cases
- Immediate DMHC help is available for serious and imminent threats to health.
Common questions
What about Medi-Cal fee-for-service or benefit eligibility?
Medi-Cal eligibility and some benefit decisions are appealed through a State Hearing with the California Department of Social Services, a separate process.
Official sources for this guide
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