External Review – California

Who should I call if I have any questions about filing a complaint?

You can contact the California Department of Managed Health Care Help Center at (888) 466-2219. The help center is available from 8:00 a.m. to 6:00 p.m. Monday through Friday.

What happens after the Department receives my complaint?

Once you submit your complaint, an analyst, a nurse consultant, or a lawyer will review it and make a decision. That person may examine your account, records, documents, and transactions. He or she may question witnesses, request additional documents from...

How do I file a complaint?

If you are a California resident and your insurer denies your coverage after the independent medical review process, you can file a complaint with the DMHC.[13] Complaint information. You can obtain a copy of the complaint form here. Your complaint should include...

How long will the independent medical review process take?

If DMHC is overseeing your independent medical review, the process should take no more than 30 days. If the review is urgent, the process should take no more than seven days after your case has qualified for an independent medical...

How do I request an independent medical review?

You must submit a request for an independent medical review within six months of receiving the last determination letter from your insurer. This deadline may be shorter if you are insured through your employer and the plan is “self-insured.” You...

In which circumstances can I apply for an independent medical review?

During an independent medical review (also referred to as an “external review”), an independent third party reviews your insurer’s decision.[3] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under California...

How long should the internal appeals process take?

Your insurer should provide you with a decision on the appeal within 30 days if you are requesting prior authorization, within 60 days if you already received medical services but are waiting for reimbursement, and within 72 hours if your...

How do I appeal the decision?

If your insurer denies your claim, you have the right to an internal appeal.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should take the following steps...

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