Your California Health Insurance Claim Was Denied. Here's What to Do Next.
A denial from your health insurance company is not a final answer. California law gives most residents the right to appeal, including through a free state-run independent review that the insurer must legally comply with if it overturns the denial.
Related: Your California Health Insurance Claim Got Denied - Here's How to Fight It · How to Appeal a Denied Health Insurance Claim in California: Your Rights and Where to Start
Start With an Internal Appeal
Every denial letter is required to explain why the claim was rejected and how to appeal it. The first step is almost always an internal appeal filed directly with your insurer, asking a different reviewer to take a fresh look at the decision. Keep a copy of the denial letter, your plan documents, and any supporting records from your doctor — a strong appeal usually includes a letter from the treating physician explaining why the denied care was medically necessary.
Insurers generally have 30 days to respond to a standard appeal, but if a delay could seriously harm your health, you can request an expedited review, which must typically be decided within 72 hours.
Escalate to a State Regulator
If the internal appeal doesn't resolve things, most Californians can take the fight outside the insurance company entirely. Which state agency handles the complaint depends on the type of plan: HMO and most PPO plans are regulated by the Department of Managed Health Care (DMHC), while some PPO and indemnity plans fall under the California Department of Insurance (CDI). Both agencies offer a free Independent Medical Review (IMR), where outside medical experts with no ties to your insurer decide whether the denied treatment should have been covered.
If the IMR rules in your favor, the insurer is legally required to authorize the treatment — it isn't a recommendation, it's binding. The DMHC reports that patients win a meaningful share of these reviews, particularly on medical-necessity denials, making it one of the most effective tools a denied patient has.
See also: Denied a Health Insurance Claim in California? Here's How to Fight Back · How to File a Health Insurance Complaint in California and Get Your Claim Reviewed
Get Help if You're Stuck
The Department of Managed Health Care's Help Center (1-888-466-2219) can walk you through which agency handles your plan and file a complaint on your behalf at no cost. Community health consumer groups and legal aid clinics across the state also assist with appeals, and for complex or high-dollar denials, some patients bring in a healthcare attorney who works on contingency.
Throughout the process, keep a written log of every call, the name of who you spoke with, and the date — insurers are required to respond within set deadlines, and a clear paper trail makes it much harder for a claim to quietly fall through the cracks.