New to helping someone in California?
Start with three things from the patient or family:
- Insurance card — shows the plan name and customer service number
- Denial letter, Notice of Appeal Resolution (NAR), or explanation of benefits (EOB) — lists deadlines and appeal rights
- Summary of Benefits and Coverage (SBC) — if available
California plans use terms like grievance, adverse benefit determination, appeal, and Independent Medical Review (IMR). The denial letter is still your roadmap.
For steps that work in every state, use these general guides first, then return here for California rules:
What is different in California?
- Covered California: California runs its own state-based Marketplace at coveredca.com (not HealthCare.gov for enrollment). Eleven carriers offer individual/family plans for 2026, including Kaiser Permanente, Anthem Blue Cross, Blue Shield of California, Health Net, and Molina (healthinsurance.org — California Marketplace).
- Two main regulators for commercial coverage: Most HMO and managed care plans are licensed by DMHC (Knox-Keene Act). Traditional indemnity/PPO policies are regulated by CDI. The same card brand can fall under either—check the plan documents and denial letter.
- Independent Medical Review (IMR): After internal review, many Californians can get a binding outside medical review through DMHC or CDI, depending on plan type (HSC § 1374.30; Ins. Code § 10169).
- Strong prior authorization timelines: Many plans must decide non-urgent medical PA within 5 business days and urgent cases within 72 hours, with deemed-approval rules for many prescription requests (HSC § 1367.01, HSC § 1367.241).
- Medi-Cal is separate: Managed care plans use MCP appeals and Medi-Cal fair hearings through DHCS—not the same path as commercial IMR.
Who is in charge of your plan?
- DMHC Help Center: Most Knox-Keene health care service plans (Kaiser, many HMOs, most Covered California QHPs) — 1-888-466-2219 (TTY 1-877-688-9891), dmhc.ca.gov
- California Department of Insurance (CDI): Many traditional health insurance policies — 1-800-927-4357, insurance.ca.gov
- DHCS / Medi-Cal: Managed care appeals and state fair hearings — dhcs.ca.gov
- CMS: Medicare and Medicare Advantage
- U.S. Department of Labor: Many self-funded employer plans
Not sure which agency? DMHC and CDI can forward misrouted complaints. For filing after appeals, see Regulator complaints.