Health Insurance Denied Your Claim? California Appeal Letter & DMHC Complaint Guide

California's Secret Weapon: Independent Medical Review (IMR)

Unlike most states, California offers a FREE Independent Medical Review process. When your insurer denies coverage, an independent doctor reviews your case. Key benefits:

Completely free - No cost to you for the review
Binding on insurers - If IMR rules in your favor, your insurer MUST comply
High success rate - Over 60% of medical necessity denials are overturned
Fast for urgent cases - 72-hour decisions for emergencies
Independent doctors - Reviewers have no connection to your insurer

How to request IMR: Contact DMHC at 1-888-466-2219 or visit dmhc.ca.gov

⚖ California Laws That Protect You

California has some of the strongest health insurance consumer protections in the nation. Know your rights:

Health & Safety Code 1368-1368.04 - Grievance and Appeal Rights

HMOs must have a grievance system that allows you to challenge any denial. You have the right to an internal appeal and then external review through DMHC. The insurer must respond to grievances within 30 days (or 72 hours for urgent cases).

Insurance Code 10123.135-10123.147 - Utilization Review Standards

Insurers must use licensed physicians to make medical necessity decisions. Denials must be communicated in writing with specific reasons. Prior authorization decisions must be made within 5 business days (72 hours for urgent requests).

DMHC (Department of Managed Health Care) - HMO Oversight

DMHC regulates HMOs and some PPOs in California. They handle complaints, facilitate IMR, and can order insurers to provide coverage. Call their Help Center: 1-888-466-2219.

CDI (California Department of Insurance) - PPO Oversight

CDI regulates traditional PPO plans. If your plan is regulated by CDI (check your policy), file complaints at insurance.ca.gov or call 1-800-927-4357.

Independent Medical Review (IMR) Process

California's IMR allows independent doctors to review your case when coverage is denied. The process is free, and the decision is BINDING on your insurer. If IMR says you should be covered, your insurer must provide coverage.

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Which Agency Regulates Your Plan?

Check your insurance card or policy documents. HMOs are typically regulated by DMHC; PPOs by CDI. If unsure, call DMHC first - they'll tell you if you need to contact CDI instead.

📄 Common Types of Insurance Denials

Health insurers deny claims for various reasons. Understanding your denial type helps you craft the right appeal:

Medical Necessity Denial

Insurer claims the treatment, procedure, or medication isn't "medically necessary." This is the most common denial and the most frequently overturned on appeal. Get your doctor to write a strong letter of medical necessity.

Prior Authorization Denial

Your request for pre-approval was denied before treatment. You can appeal immediately. For urgent care, request expedited review - insurers must respond within 72 hours for urgent prior auth requests.

Experimental/Investigational Denial

Insurer claims the treatment is experimental or not proven effective. Provide peer-reviewed studies, FDA approvals, and expert opinions showing the treatment is accepted medical practice for your condition.

Out-of-Network Denial

Coverage denied because provider isn't in network. If no in-network provider was reasonably available, or you weren't properly informed, California law may require coverage at in-network rates.

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Read Your Denial Letter Carefully

Your denial letter must explain the specific reason for denial and how to appeal. If the reason is vague or missing, that itself may be a violation of California law. Note all deadlines mentioned in the letter.

💰 What You Can Recover

When your insurer wrongly denies coverage, here's what you may be entitled to:

Damage Type	Description
Full Claim Payment	The complete amount of the denied claim - what your insurer should have paid in the first place
Treatment Coverage	For prior auth denials: approval and coverage of the requested treatment going forward
Interest on Delayed Payments	California law requires insurers to pay interest on unreasonably delayed claims (10% per year under some circumstances)
Out-of-Pocket Expenses	Reimbursement for costs you paid that should have been covered
Bad Faith Damages	If insurer acted unreasonably (ignored evidence, delayed without reason), you may recover additional damages through litigation
Attorney Fees	In bad faith cases, courts may award attorney fees in addition to damages

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IMR = Fastest Path to Coverage

The IMR process typically resolves coverage disputes within 30-45 days. If you need the treatment quickly, this is often faster than litigation and is completely free.

📝 Appeal Letter Template

Use this letter to appeal your insurance denial. Send via certified mail with return receipt requested, and keep a copy for your records.

APPEAL OF HEALTH INSURANCE CLAIM DENIAL [Your Name] [Your Address] [City, CA ZIP] [Phone] [Email] [Date] VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED [Insurance Company Name] Appeals Department [Insurance Company Address] [City, State ZIP] Re: Appeal of Claim Denial Member Name: [Your Name] Member ID: [Your Member ID Number] Claim Number: [Claim Number from Denial Letter] Date of Service: [Date(s) of Service] Provider: [Doctor/Hospital Name] Denial Date: [Date of Denial Letter] Dear Appeals Department: I am writing to formally appeal your denial of coverage for [describe treatment/procedure/medication] dated [denial date]. Your denial letter stated the reason as: [quote the denial reason from the letter]. I respectfully request that you reverse this denial for the following reasons: MEDICAL NECESSITY: [Explain why the treatment is medically necessary. Include:] - My diagnosis is [your diagnosis] - This treatment is necessary because [explain medical need] - My treating physician, [Doctor's Name], has determined this is the appropriate treatment because [doctor's reasoning] - Without this treatment, my condition will [describe consequences of non-treatment] COVERAGE UNDER MY POLICY: My policy, [Plan Name], covers [type of treatment] under the following provisions: [Quote relevant policy language that supports coverage] The treatment I am requesting falls squarely within this covered benefit because [explain how treatment fits coverage]. SUPPORTING DOCUMENTATION: I am enclosing the following documents in support of this appeal: 1. Letter of Medical Necessity from [Doctor's Name] 2. Relevant medical records documenting my condition 3. [Peer-reviewed studies, clinical guidelines, or other supporting evidence] 4. Copy of the denial letter REQUEST FOR EXPEDITED REVIEW: [Include if applicable:] Due to the urgent nature of my medical condition, I request expedited review of this appeal. Delay in treatment could result in [describe serious consequences]. Under California law, you must respond to urgent appeals within 72 hours. NOTICE OF FURTHER ACTION: If this appeal is denied, I intend to exercise my right to an Independent Medical Review (IMR) through the California Department of Managed Health Care. Under California Health & Safety Code Section 1368.02, the IMR decision will be binding on [Insurance Company Name]. I also reserve all rights under California Insurance Code Sections 10123.135-10123.147 regarding timely claim decisions and bad faith. Please respond to this appeal within thirty (30) days as required by California law. If I do not receive a satisfactory response, I will file a complaint with the [DMHC or CDI, depending on your plan type] and request an Independent Medical Review. Sincerely, _______________________________ [Your Signature] [Your Printed Name] Enclosures: - Denial letter dated [Date] - Letter of Medical Necessity from [Doctor] - Relevant medical records - [Any additional supporting documentation] cc: [Your doctor] California Department of Managed Health Care (if filing complaint)

📋 Evidence Checklist for Your Appeal

Gather these documents before submitting your appeal. Strong documentation significantly improves your chances:

✓ Denial letter - The official denial with specific reason and claim number
✓ Policy documents - Your Evidence of Coverage (EOC) or Summary Plan Description showing covered benefits
✓ Medical records - Records documenting your diagnosis, treatment history, and current condition
✓ Letter of Medical Necessity - Written by your treating physician explaining why the treatment is medically necessary
✓ Prior authorization request - Copy of the original request and any communications
✓ Similar case approvals - If your insurer approved similar treatments for you or others, document this
✓ Clinical guidelines - Published medical guidelines supporting the treatment for your condition
✓ Peer-reviewed studies - Research supporting the effectiveness of the treatment

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Your Doctor is Your Best Advocate

Ask your doctor to write a detailed Letter of Medical Necessity. This is often the most important piece of your appeal. The letter should explain your diagnosis, why this specific treatment is necessary, what alternatives have been tried, and what happens if treatment is denied.

📅 The California Appeal Process

Step 1: Internal Appeal (Required First)

File an appeal directly with your insurance company within 60 days of denial. They must respond within 30 days (72 hours for urgent cases). This step is required before requesting IMR.

Step 2: Request Independent Medical Review (IMR)

If internal appeal is denied, request IMR through DMHC within 6 months. Call 1-888-466-2219 or visit dmhc.ca.gov. IMR is free and the decision is binding on your insurer.

Step 3: IMR Review (30-45 Days Standard)

Independent doctors review your case. For urgent cases, decisions come within 72 hours. Standard cases take 30-45 days. Over 60% of medical necessity cases are decided in favor of patients.

Step 4: IMR Decision is Final

If IMR rules in your favor, your insurer MUST provide the coverage or pay the claim. They cannot appeal the IMR decision. If IMR denies, you can still pursue legal action.

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Don't Miss Deadlines!

Internal appeal: Usually 60 days from denial. IMR request: 6 months from denial of internal appeal. For urgent medical situations, you can request expedited review at any stage. When in doubt, file sooner rather than later.

❓ Frequently Asked Questions

How do I appeal a health insurance denial in California?

In California, you have the right to appeal any health insurance denial. First, file an internal appeal with your insurance company within 60 days of the denial. If denied again, you can request an Independent Medical Review (IMR) through the Department of Managed Health Care (DMHC) for HMOs or the California Department of Insurance (CDI) for PPOs. The IMR is free and the decision is binding on the insurer.

What is an Independent Medical Review (IMR)?

An Independent Medical Review (IMR) is a free California process where independent doctors review your case when your health insurance denies coverage. If the IMR rules in your favor, your insurer MUST provide the treatment or pay the claim. IMR decisions are binding on the insurer. The IMR process typically takes 30-45 days for standard cases, or 72 hours for urgent cases.

How do I file a complaint with DMHC?

You can file a complaint with the Department of Managed Health Care (DMHC) online at dmhc.ca.gov or by calling 1-888-466-2219. DMHC regulates HMOs and some PPOs in California. When filing, include your denial letter, policy information, medical records supporting your case, and your doctor's letter of medical necessity. DMHC can help resolve disputes and facilitate Independent Medical Review.

What is the deadline to appeal a denial?

For internal appeals, you typically have 60 days from the denial notice to file. For IMR requests through DMHC, you generally have 6 months from the denial of your internal appeal. However, for urgent medical situations, you can request expedited review that bypasses internal appeals. Don't wait - the sooner you appeal, the better your chances.

Can I get emergency treatment approved quickly?

Yes. California law requires expedited review for urgent cases. If your health condition is serious and delay would cause harm, you can request expedited internal appeal (must be decided within 72 hours) or expedited IMR through DMHC (decided within 72 hours). Call DMHC at 1-888-466-2219 for urgent cases. Your doctor can also request expedited prior authorization.

What if my insurer delays my claim instead of denying it?

Under California Insurance Code 10123.135, insurers must make timely decisions on claims and prior authorizations. For urgent requests, decisions must be made within 72 hours. For non-urgent requests, 5 business days. If your insurer is unreasonably delaying, file a complaint with DMHC or CDI. Unreasonable delays can constitute bad faith, potentially entitling you to additional damages.

Complex Insurance Denial? I Can Help.

For large claims, bad faith situations, or when you need aggressive representation against your insurer, I can assist with appeals, complaints, and litigation.

Contact: owner@terms.law

📅 Schedule a Consultation

For complex insurance disputes, denied cancer treatment, or claims involving significant amounts, book a call to discuss your options.

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Health Insurance Denied Your Claim? Fight Back with California's Free IMR Process.