How appeals work in California
When a California-regulated plan denies, delays, or changes coverage, you usually get a written notice. That notice should explain how to challenge the decision inside the plan—through a grievance, an appeal of an adverse benefit determination, or both.
Think of internal review as asking the plan to reconsider. If that fails, many Californians can request Independent Medical Review (IMR) through DMHC or CDI, depending on who regulates the plan.
Universal how-to: Appeals roadmap and Building a strong appeal packet.
Grievance vs appeal
California law distinguishes two paths (HSC § 1368):
- Grievance:a complaint about the plan's actions (billing, access, customer service, delays). Plans must resolve most grievances within 30 calendar days (HSC § 1368.01).
- Appeal (adverse benefit determination): a request to overturn a denial, modification, or delay of a specific service based on medical necessity, experimental/investigational status, or similar clinical reasons. You often have about 60 days from the notice to start (Medi-Cal managed care rules; commercial plans list their deadline on the notice).
You do not need to use the magic word "grievance"—if you express dissatisfaction, the plan should treat it as one. For a clinical denial, also file an appeal if the notice says to.
The usual steps
- Adverse benefit determination or denial notice — read appeal rights and deadlines.
- File with the health plan — use the fax, portal, or address on the notice. Keep proof of submission.
- Plan acknowledgment — many plans must acknowledge appeals within about 5 days.
- Notice of Appeal Resolution (NAR) or grievance response — explains whether the plan upheld or overturned the denial.
- IMR or regulator complaint — if still denied, see California external review (IMR).
DMHC's process overview: dmhc.ca.gov — File a Complaint.
How long the plan has to answer
Standard grievances and appeals
- Grievances: resolved within 30 calendar days (HSC § 1368.01(a))
- Appeals of adverse benefit determinations: many plans must issue a written decision within 30 calendar days (standard) under Knox-Keene regulations (28 CCR § 1300.68)
Urgent / expedited
If there is an imminent and serious threat to health (severe pain, potential loss of life or limb, etc.):
- Grievances: written disposition within 3 days of receipt (HSC § 1368.01(b))
- Appeals: often 72 hours for expedited medical review (plan documents and Medi-Cal guidance)
CDI-regulated insurance
Follow the appeal/grievance instructions on your denial. If the insurer does not rule within 30 days, you may be able to seek IMR through CDI (CDI — IMR program).
If the plan is late
If the plan does not resolve a grievance within 30 days, you can generally go to DMHC for IMR or a consumer complaint without waiting longer (HSC § 1368(b)). For appeals, if the plan misses its deadline, the failure may be treated as a denial—check the notice and external review options.
Document when you filed and what the plan returned, if anything.
What comes next?
For DMHC-regulated plans, you usually must participate in the plan's grievance process for 30 days before DMHC will process an IMR—unless the case is urgent (about 3 days of plan review) or involves experimental/investigational treatment (you may skip straight to IMR in some cases).
File IMR within 6 monthsof the plan's written grievance or appeal resolution (28 CCR § 1300.74.30).
California external review (IMR) · Self-funded ERISA plans
Medi-Cal: after a NAR, you may have about 120 days for a state fair hearing—often shorter than the 6-month IMR window. You can request both, but hearing deadlines keep running (Disability Rights California — IMR).
Key takeaway
Read the denial, file the right process (grievance and/or appeal) before the plan's deadline, and calendar the 30-day plan response window. If the plan is late or you get a final denial, California's IMR system is one of the strongest external review tools in the country—if your plan is state-regulated.