If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:
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 within 30 days of receiving the denial letter from your insurer:
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 case is urgent.[2]
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 law, you are entitled to request an independent medical review in the following circumstances:
You can request an expedited independent medical review at the same time that you request an expedited internal appeal in urgent situations.[5]
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 should check with your employer for more information.
You must determine where to file your independent medical review. This determination depends on what type of plan you have.
HMOs, PPOs, and Specialized Plans. The California Department of Managed Healthcare (“DMHC”) regulates all health maintenance organizations (HMOs), some preferred provider organization (PPO) plans, as well as specialized plans that cover only certain kinds of care, such as certain dental and vision care plans, behavioral or mental health plans, and chiropractic plans.[6] If you need help figuring out if DMHC regulates your plan, you should visit www.hmohelp.ca.gov or call DMHC at 1-888-466-2219.
If your plan is regulated by the DMHC, you should submit a request for an independent medical review here. You should include any new information and documentation with your application. You can also print a copy of the application and fax it to (916) 255-5241 or mail it to:
Help Center
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814-2725[7]
Fee-for-service plans and PPOs. The California Department of Insurance (“CDI”) regulates indemnity health insurance plans, also known as fee-for-service plans, and most PPO plans.[8] You can call the CDI at 1-800-927-4357 to find out whether it regulates your specific plan.
If your plan is regulated by the CDI, you should apply for an independent medical review here. You should include any new information and documentation with your application. You can also print a copy of the application and fax it to (213) 897-9641 or mail it to:
Department of Insurance, Health Claims Bureau
300 S. Spring Street, South Tower
Los Angeles, CA 90013
Self-funded plans. If you receive your health insurance through your employer, check with your employer to see if your plan is “self-funded.” Neither DMHC nor CDI regulate these types of plans. If your plan is a self-funded employer plan, ask your employer to provide you with the contact information for the plan’s administrator to find out what your independent review options are.
Expedited independent medical review requests. If you seek an expedited independent medical review, ask your health care provider to certify, in writing, that a delay in receiving the requested treatment or service would create a serious and imminent risk to your health.[9]
Insurer’s responsibility. If your request for an independent medical review is granted, your health insurer has 24 hours to provide the necessary documentation and information to the independent medical reviewer.[10]
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 review and the required documents have been received.[11]
If the CDI is overseeing your case, the independent medical review process should take no more than 45 days. If you request an expedited independent review, the process should take no longer than three days after the independent medical reviewer receives your request.[12]
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 the following information:
Supporting documents. You should submit the following supporting documents with your complaint:
You can submit the complaint and supporting documents online here, fax them to (916) 255-5241, or mail them to:
Help Center
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814-2725[16]
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 other parties, and hold a hearing.[17] The Department will then send you and your insurance plan notice of its decision.[18]
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.