Your appeal failed in California. External review is the next step.
When your plan turns down the internal appeal, California lets doctors who do not work for your plan read the decision again. Here is who runs it and where to file. The filing window is the one thing this page does not state for you: read it off your denial letter and the regulator's own page.
California Department of Managed Health Care
Not verified for California. Your denial letter states your deadline, and the California Department of Managed Health Care page linked below confirms it.
California calls it Independent Medical Review. File a grievance with your plan first; you can go to the DMHC Help Center once the plan has answered, or after 30 days without an answer. The DMHC regulates most plans in the state, and some PPO and indemnity policies are regulated by the California Department of Insurance instead, which runs its own review. Your denial letter names the regulator to write to.
Deadlines and forms change. The regulator's page and your own denial letter are the authority on your case; this page is not.
Last reviewed
Someone outside your plan reads the file.
- The plan reviews itself first.An internal appeal is your plan looking again at its own decision, under its own criteria.
- Then the state hands it to outsiders.External review, also called independent medical review, sends the case to clinicians with no stake in the answer. In most states the decision binds the plan.
- It turns on medical judgment.External review is generally for denials that rest on medical necessity, on whether care is experimental or investigational, and on similar clinical calls, rather than on a plain contract exclusion.
Usually after the internal appeal. Sooner if it is urgent.
- Exhaust the internal appeal.Most states want the plan's own appeal finished, and the final denial letter is what starts the clock.
- Ask for the urgent route where care cannot wait.Where a treating clinician certifies that a delay would seriously jeopardise health, states run an expedited review and many let it begin before the internal appeal ends.
- File in writing, in time.The window is set by your state and stated on your denial letter. Miss it and the option usually closes, so read the letter before anything else.
If your coverage comes from a self-funded employer plan
Many large employers pay claims out of their own funds and hire an insurer only to administer the plan. Those plans are governed by the federal ERISA framework rather than by California insurance law, so California Department of Managed Health Care generally cannot take the case and the appeal follows the federal external review process instead. Your plan documents or benefits office will say whether the plan is self-funded, and the denial letter names the review process that applies to you.
A physician writes the argument the reviewer reads.
External review is decided on the record you send. A licensed physician reads your records, tells you candidly whether the case has merit, and writes the letter that answers the plan on its own clinical terms, with the guidelines and evidence cited. We advocate rigorously; no one can promise you an outcome.
Cove Health provides advocacy services. Information on this site is general information, not legal or medical advice. Cove Health is not a law firm and does not provide legal representation, and submission of records does not guarantee a particular outcome.