State guide

California

Pick the kind of plan you have to see who to call first. California can only help with plans it regulates.

On this page 8

Which plan do you have?
Quick facts for independent review
Who regulates health plans
Independent (external) review
Free help in California
Medicare and Medicaid in California
State laws that can help
Sources and what we could not confirm

Which plan do you have? Who to call first, by coverage

Your employer pays claims itself

California usually cannot help with these plans. Call the Employee Benefits Security Administration.

Call 1-866-444-3272
Insurance you buy, or an employer plan bought from an insurer

Call California Department of Managed Health Care (DMHC). See the at-a-glance box.

Call 1-888-466-2219
Medicaid or children's coverage

Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in California.

Medicaid in California
Medicare

California Health Insurance Counseling and Advocacy Program (HICAP) gives free counseling. Or call 1-800-MEDICARE.

Call 1-800-434-0222 1-800-633-4227

The short version for California

California has two health insurance regulators, and which one you use depends on your plan: the Department of Managed Health Care (DMHC) oversees Health Maintenance Organizations (HMOs) and most other health plans, and the California Department of Insurance (CDI) oversees health insurance policies. Both run a free external review called Independent Medical Review (IMR), and the Department of Managed Health Care says about 78% of people who ask it for one end up getting the care they requested. Free one-on-one help is available from the Health Consumer Alliance, and you have six months after your plan's appeal decision to ask for a review.

At a glance: independent review for plans California regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator: California Department of Managed Health Care (DMHC) · 1-888-466-2219 (TDD: 1-877-688-9891)
Independent review: A state process (Independent Medical Review (IMR))
Deadline to request it: 6 months after your plan sends its written response to your appeal (both departments). Either department may accept a late request if circumstances prevented you from filing on time.
Cost: None. The review is free to the patient under both departments.
Decision time: Department of Managed Health Care: usually decided within 45 days after it has the supporting documents. Department of Insurance: the review organization must finish within 30 days.; fast track: Department of Managed Health Care: usually within 7 days when your doctor documents that the problem is urgent. Department of Insurance: within 3 days when your doctor or the department certifies an imminent and serious threat to your health.

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

Neither regulator publishes an insurance-card rule, but you do not have to work it out alone. Your plan's denial or appeal decision letter should name the regulator and include its review form (the Department of Insurance says insurers must send its Independent Medical Review application with the denial letter). The Department of Managed Health Care publishes a list of every plan it licenses (https://wpso.dmhc.ca.gov/hpsearch/viewall.aspx); if you file with it and your plan belongs to the Department of Insurance, it forwards your complaint. If you do not know what kind of plan you have, the Department of Insurance says you can call 1-800-927-4357.

California Department of Managed Health Care (DMHC)
All California Health Maintenance Organization (HMO) plans, some Preferred Provider Organization (PPO) plans, Medi-Cal managed care plans, and the vast majority of Covered California (state marketplace) plans. It does not handle Medicare, Medi-Cal members who are not in a managed care plan, or self-insured (self-funded) employer plans.

Phone: 1-888-466-2219 (TDD: 1-877-688-9891). File a complaint online
California Department of Insurance (CDI)
Health insurance policies sold by insurance companies in California (many Preferred Provider Organization policies), including a small share of Covered California plans. It does not handle Medi-Cal, Medicare or self-insured employer plans.

Phone: 1-800-927-4357 (1-800-927-HELP). File a complaint online

Independent (external) review

Process: A state process. Run by The Department of Managed Health Care (DMHC) Help Center for health plans it licenses, and the California Department of Insurance (CDI) for health insurance policies. Each department screens the request and sends qualifying cases to an independent medical review organization under state contract.
Where you file: regulator
How: First file a grievance (appeal) with your plan and wait for its decision or 30 days, whichever comes first. Then send one Independent Medical Review/Complaint form to the regulator for your plan: online, by mail or by fax to the Department of Managed Health Care (1-888-466-2219), or the Application for Independent Medical Review to the Department of Insurance (1-800-927-4357). Send everything at once: the Department of Managed Health Care does not review documents sent after a complete form is submitted.
Which denials qualify: Denials, delays or changes to a service because the plan says it is not medically necessary; refusals to cover a treatment as experimental or investigational; and refusals to pay for emergency or urgent care you already received. A denial because the service is not a covered benefit does not qualify, but the same form is then handled as a consumer complaint and the department checks whether the plan applied your coverage correctly.
Appeal to the plan first?: Yes. You must file a grievance with your plan and take part in its process for 30 days. Exceptions the Department of Managed Health Care states: you may go straight to it if there is a serious threat to your health, or if the plan denied the treatment as experimental or investigational. The Department of Insurance says it may waive the plan appeal step in extraordinary and compelling cases.
Published results: The Department of Managed Health Care says approximately 78% of enrollees who request an Independent Medical Review receive the service or treatment they asked for, counting cases where the plan reversed itself after the request was filed and cases the independent reviewers overturned (figure from its 2025 Annual Report). This covers plans it regulates only. Source

Official page Request form Search past decisions

General rules and what to send: how external review works, how to request it.

Free help in California

Health Consumer Alliance
A statewide partnership of legal aid organizations, under contract with the Department of Managed Health Care, that gives free phone or in-person help with filing a grievance with your health plan, filling out the Independent Medical Review form, medical bills and Medi-Cal problems.

Phone: 888-804-3536
Medi-Cal Managed Care and Mental Health Office of the Ombudsman
Helps people in Medi-Cal (California Medicaid) managed care plans who have problems with their plan, including denied or delayed care.

Phone: 1-888-452-8609
Health Insurance Counseling and Advocacy Program (HICAP)
Free, confidential counseling for people with Medicare, including help filing an appeal or challenging a denial, and legal help or referrals for Medicare and long-term care insurance problems.

Phone: 1-800-434-0222

Medicare and Medicaid in California

Medicare counseling: California Health Insurance Counseling and Advocacy Program (HICAP) · 1-800-434-0222 . Free help with Medicare appeals.
Medicaid agency: California Department of Health Care Services (Medi-Cal). State hearings are run by the California Department of Social Services, State Hearings Division.
Fair hearing deadline: If a Medi-Cal managed care plan made the decision: 120 calendar days from the date of the plan's Notice of Appeal Resolution. If the county or the Department of Health Care Services made the decision: 90 days. Your notice states the deadline that applies to you.
Good to know: If the decision came from a Medi-Cal managed care plan you generally must appeal to the plan first, within 60 calendar days of the date on the notice of action; you can ask for a state hearing if the plan has not answered within 30 days. Plan notices say that to keep getting a service the plan is cutting or stopping, you must ask for the appeal within 10 days of the notice date or before the change takes effect. You can request a hearing by phone at (800) 743-8525. Medi-Cal managed care members can also ask the Department of Managed Health Care for an Independent Medical Review. A temporary extension to 120 days applies only to hearings about Medi-Cal eligibility renewals, not to denied treatments or services.

Medicaid appeals page How Medicaid appeals work

State laws that can help

External review. Independent Medical Review is free, the independent doctors' decision is binding on the plan or insurer, and if you win the plan must authorize the service (within five business days for plans under the Department of Managed Health Care).

California Health and Safety Code sections 1374.30 and 1370.4; California Insurance Code sections 10169 to 10169.5 and 10145.3
AI in utilization review. A health plan or insurer that uses artificial intelligence, an algorithm or other software in deciding whether care is medically necessary must make sure the tool bases its determination on the individual patient's information and is applied fairly and equitably.

Senate Bill 1120 (2024), Chapter 879; Health and Safety Code section 1367.01 and Insurance Code section 10123.135
Step therapy. Your plan must quickly grant an exception to step therapy (a rule that you try a cheaper drug first) when your prescriber documents that the required drug is not right for you, you can appeal a denied exception, and a request is treated as approved if the plan does not answer in time.

Assembly Bill 347 (2021); Health and Safety Code section 1367.206 and Insurance Code section 10123.201
Mental health parity. Plans and insurers must cover medically necessary treatment of mental health and substance use disorders on the same terms as other medical conditions, cannot limit it to short-term or acute care, and must decide medical necessity using current generally accepted standards of care.

Senate Bill 855 (2020), Chapter 151; Health and Safety Code sections 1374.72 and 1374.721 and Insurance Code sections 10144.5 and 10144.52
Surprise billing. If you get non-emergency care at an in-network facility from an out-of-network provider you did not agree to in writing, you owe only your in-network share of the cost. This does not apply to Medi-Cal, Medicare or self-insured plans.

Assembly Bill 72 (2016), Chapter 492; Health and Safety Code section 1371.9 and Insurance Code section 10112.8
Prior authorization. Not yet in force for patients: plans and insurers must report their prior authorization approval rates, the state must publish by July 1, 2027 a list of services approved at least 90% of the time, and plans must stop requiring prior authorization for those services by a date the regulators set, no later than January 1, 2028.

Senate Bill 306 (2025), Chapter 408; Health and Safety Code section 1367.025 and Insurance Code section 10133.52

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on 2026-11-11. Phone numbers and deadlines change; check the official page before you rely on one.

Not confirmed (11)

How long a standard independent review takes. the Department of Managed Health Care's own pages disagree: the frequently asked questions page says an Independent Medical Review is usually decided within 45 days in one answer and within 30 days of qualification in another, and the paper form says the review organization usually decides within 30 days. The 45-day figure is used as the cautious one.
Published results of independent review. the web page says approximately 78% (2025 Annual Report) but the paper form revised 09/25 still says approximately 73 percent; the annual report itself was not opened. No overturn rate for the Department of Insurance was confirmed: its statistics tool (https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192) redirects to a session page that could not be read.
The independent review request form. this is the Department of Managed Health Care form only. The Department of Insurance form is https://www.insurance.ca.gov/01-consumers/101-help/upload/IMR.pdf; the schema has one field.
A searchable list of past decisions. covers Department of Managed Health Care decisions only; no searchable decision database for the Department of Insurance was confirmed.
Not confirmed. regulators[0].complaintUrl and jurisdictionTip plan list URL — the wpso.dmhc.ca.gov tools refuse automated requests (HTTP 403); the online form address and plan list address come from this project's earlier research report and the search index, not from a page loaded in this session. The decision search page text was read through the search index.
The state regulators. the link is printed on the Department of Insurance 'Getting Help' page and responds, but it is a sign-in portal that was not entered.
How to tell whether the state regulates your plan. assembled from several official statements; neither department publishes a rule for reading an insurance card.
Free consumer help programs. the Medi-Cal ombudsman phone number is confirmed on the Department of Managed Health Care and Centers for Medicare & Medicaid Services pages, but no ombudsman page on dhcs.ca.gov could be read (the Department of Health Care Services site returned empty content to every fetch tool); the URL given is that department's fair hearing page, which responds but whose text was not read.
Notes on Medicaid appeals. the 10-day rule for keeping benefits during a plan appeal was read from a Medi-Cal plan's 'Your Rights' notice attachment, not from a state web page.
State laws that help. bill texts were read on the official legislative site as enacted; later amendments to the same code sections were not checked. Insurance Code section numbers for the step therapy and surprise billing entries are taken from the bills' lists of amended and added sections. The five-business-day authorization rule is from the Department of Managed Health Care's frequently asked questions page, not the statute text.
Not confirmed. stateLaws (gold card, denial-notice) — no California law on these topics was researched or confirmed.

Sources last checked 11 November 2026. Found a mistake? Report it.