California health insurance denial: internal appeal and free IMR
UPDATED JULY 2026 · CALIFORNIA PLANS · NOT LEGAL OR MEDICAL ADVICE
California gives most denied members a genuine second opinion that costs nothing: Independent Medical Review (IMR) through the state. It has a strong track record of overturning denials involving medical judgment. The first job is figuring out which state agency actually regulates your plan, because that decides which door you knock on.
- DMHC (Department of Managed Health Care): regulates most HMOs and many managed-care plans, including most Covered California and employer HMO plans. Runs the IMR program.
- CDI (California Department of Insurance): regulates many PPO and indemnity plans. Has its own independent review process for its plans.
- Self-funded employer plans: generally exempt from both — see the ERISA carve-out below.
Your denial letter, member ID card, or Evidence of Coverage should name the regulator. If it doesn't, the DMHC Help Center can tell you in one call, and can also redirect you to CDI if that's the correct regulator for your plan.
Step 1 — File the internal appeal (grievance) with your plan
Start with your plan's internal grievance or appeal process, following the instructions and deadline in the denial notice. Keep a dated copy of everything you submit and every response you receive — the grievance record becomes the file IMR reviewers will read.
If the situation is urgent, ask the plan in writing for an expedited review at the same time — see the prior-authorization guide for how to phrase an urgent request.
Step 2 — Request Independent Medical Review (IMR)
If your DMHC-regulated plan denies, delays, or modifies care based on medical necessity, or denies coverage as experimental/investigational, you can generally ask the DMHC Help Center for an IMR. A doctor not employed by your plan reviews the medical record and the plan's stated reason, and issues a decision. Historically, DMHC has reported that a large share of IMR cases result in the denial being overturned in whole or in part — but every case turns on its own medical facts, so don't treat that as a guarantee for yours.
In an urgent situation, you can generally request an expedited IMR without waiting for the plan's internal grievance to finish. Confirm the current eligibility rules and any required forms directly with the DMHC Help Center at 1-888-466-2219, since IMR intake details can change.
Step 3 — Assemble the IMR request
- The denial notice and any grievance response from the plan, showing the stated medical or coverage reason.
- A treating-physician letter that responds directly to the plan's stated reason — this is usually the single most persuasive document in an IMR file.
- Relevant medical records: chart notes, test results, prior treatment history, and any clinical guidelines your doctor relies on.
- The IMR application itself, available through the DMHC Help Center, filled out completely and signed.
- Proof of timely filing: portal confirmation, fax receipt, or tracked mail.
The self-funded ERISA carve-out
Not every California employer plan uses DMHC or CDI review. Self-funded employer plans — where the employer, not an insurer, bears the financial risk — are typically exempt from state external review and instead follow the federal ERISA claims and appeals process, regulated by the U.S. Department of Labor rather than a California agency. Check your Summary Plan Description for language describing the plan as self-funded or self-insured, or ask your HR or benefits contact directly. If your plan is self-funded, see the external-review guide for the federal path in the meantime.
IMR request cover letter
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Frequently asked questions
What if I'm not sure whether DMHC or CDI regulates my plan?
Call the DMHC Help Center at 1-888-466-2219. If your plan turns out to be CDI-regulated instead, the Help Center can point you to CDI's process, or you can contact CDI directly.
Can I request IMR for a denial that isn't about medical necessity?
IMR is designed for disputes involving medical judgment, including "not medically necessary" and experimental/investigational determinations. Purely administrative or eligibility denials may need a different route — ask the DMHC Help Center which applies to your specific denial.
How long does IMR take?
Standard IMR decisions and expedited IMR decisions for urgent cases both run on published timeframes that can be confirmed with the DMHC Help Center when you file, since exact processing times can vary by case complexity.