Health insurance or Medicaid said no in California? Deadlines and free help

In California, state-regulated health plans are overseen by California Department of Managed Health Care (DMHC) and California Department of Insurance (CDI).

California runs its own independent review of denials: Independent Medical Review (IMR). You generally have 6 months to ask for it.

External review means a doctor or reviewer outside your plan decides again. Internal appeal means your plan looks at its own decision again.

Pick your plan type

Which kind of coverage was denied? The plan type decides which rules and deadlines apply.

Insurance I bought or got through work

Your state insurance rules may apply. First appeal to your plan, then ask for an outside review.

My employer pays claims itself (self-funded)

Federal rules apply, and most state insurance laws do not. Free help comes from the U.S. Department of Labor.

Medicaid / Medi-Cal

You ask the state for a fair hearing. In a Medicaid health plan, you usually appeal to the plan first.

Marketplace (Covered California) decision

A decision about whether you can buy a plan or get financial help is appealed to the Marketplace.

How long do I have?Urgent care: faster decisionWrite my appealFree help

Checked against official sources: October 30, 2026.

Appeal deadlines are strict. If you are near a deadline or your care is urgent, call free help today.

How long do I have in California?

Appeal to your plan
At least 180 days from receipt of the denial (federal rule)
Outside review
6 months
Hearing deadline
90 days
Appeal to the plan first
60 days (federal rule)
Then a state hearing
120 days
Appeal deadline – Covered California
90 days

All the details →

How long do I have? Deadline calculator

How do I know which plan type I have?

How to tell which agency regulates your plan

Plans regulated by the DMHC must print the DMHC phone number (1-888-466-2219) and website on plan contracts, grievance forms and denial-related notices. If your papers list the DMHC, your plan is regulated by the DMHC. Insurance policies are regulated by the CDI.

Law: Cal. Health & Safety Code 1368.02(b)

Step 1: Appeal to your plan in California

What it is called: Grievance (internal appeal) with your plan or insurer

Plans regulated by the DMHC must resolve a grievance within 30 days. For a serious and immediate threat to your health, such as severe pain or possible loss of life, limb or major bodily function, the plan must give you a written decision or status within 3 days and tell you in writing that you can contact the DMHC.

Law: Cal. Health & Safety Code 1368.01(a)-(b)

All the details →

Step 2: Outside review in California

Independent Medical Review (IMR)

Deadline to ask: 6 months.

All the details →

Urgent care in California: faster decisions

Appeal to your plan

  • Your plan must decide an urgent appeal within 3 days.

Outside review

If the service has not been provided yet and your doctor or the agency certifies an imminent and serious threat to your health, the reviewers must decide within 3 days of receiving the information.

Law: Cal. Health & Safety Code 1374.30-1374.36; Cal. Ins. Code 10169-10169.5

Standard: 30 days; Urgent: 3 days

Medicaid

You can ask for an expedited hearing by calling 1-800-743-8525.

Law: Cal. Welf. & Inst. Code 10951

Marketplace

You can ask for an expedited appeal if a standard appeal could seriously harm your life, health or ability to regain maximum function. If granted, the decision is due within 5 working days after the hearing.

Law: Cal. Gov. Code 100506.4, 100506.5

Complaints about your plan in California

For other problems with a DMHC-regulated plan, such as a coverage dispute, you can submit your grievance to the DMHC after finishing the plan's grievance process or after 30 days in it (sooner if there is an imminent and serious threat to your health). The DMHC must send its written decision within 30 calendar days. For an insurance policy, you can file a complaint with the CDI online.

Law: Cal. Health & Safety Code 1368(b); Cal. Ins. Code 10169(d)

cdiapps.insurance.ca.gov

Medicaid (Medi-Cal) denials in California

Who holds the hearing: California Department of Social Services (CDSS), State Hearings Division.

Hearing deadline: 90 days

All the details →

Marketplace decisions in California

Marketplace

Covered California · 1-800-300-1506

Appeal deadline

90 days

The date Covered California mailed your eligibility decision

How to appeal

Use the Request for a State Fair Hearing form (online at acms.dss.ca.gov, by fax or mail to the CDSS State Hearings Division, or by phone at 1-800-743-8525). Covered California may first contact you to try to resolve the issue; if not resolved, a CDSS administrative law judge holds a hearing, usually by phone.

Form

Request for a State Fair Hearing to Appeal a Covered California Eligibility Determination

Faster appeal

You can ask for an expedited appeal if a standard appeal could seriously harm your life, health or ability to regain maximum function. If granted, the decision is due within 5 working days after the hearing.

Coverage while you appeal

You can ask to keep your coverage while you appeal (Continued Enrollment). If you appeal a redetermination of your financial help, you keep the same level of help while the appeal is pending.

If you disagree

If you disagree with the decision, you can appeal to the U.S. Department of Health and Human Services within 30 days of the decision notice.

Law: Cal. Gov. Code 100506.4, 100506.5

Other rights in California

Who decides medical necessity

Only a licensed physician or a qualified licensed health care professional may deny or change a request based on medical necessity. Since January 1, 2025, a plan's or insurer's artificial intelligence or software tool may not deny, delay or change care based on medical necessity.

Law: Cal. Health & Safety Code 1367.01(e), (k); Cal. Ins. Code 10123.135 (SB 1120, Stats. 2024, ch. 879)

How fast a plan must decide a prior approval

A plan or insurer must decide a request for prior or ongoing approval within 5 business days of getting the information it needs, or within 72 hours (or less) if waiting could seriously harm your life or health. Decisions after care was given must be made within 30 days.

Law: Cal. Health & Safety Code 1367.01(h); Cal. Ins. Code 10123.135(h)

How long do I have? Deadline calculator

Pick your plan type and enter the dates on your notice. We count from the rules in California and the federal rules.

Worked out in your browser. Nothing you enter here is saved or sent.

If you are not sure when it arrived, use the date printed on the notice. That date is never later than the day it arrived.

Choose what was decided and enter the date on your notice

We add the number of days or months from the law to your date. Nothing is saved.

Write my appeal: free letters

Free help in California

Good to know in California

  • California has two separate state independent medical review programs: one at the DMHC for health care service plans and one at the CDI for insurance policies.

    Law: Health & Safety Code 1374.30; Ins. Code 10169

  • California gives 6 months to apply for IMR, longer than the federal minimum of 4 months for external review.

    Law: Health & Safety Code 1374.30(k); Ins. Code 10169(k)

  • Medi-Cal members in DMHC-regulated managed care plans are not excluded from IMR.

    Law: Health & Safety Code 1374.30(f)

Changes in 2024–2026

January 1, 2025: SB 1120 bars plans and insurers from letting AI or software tools deny, delay or modify care based on medical necessity. Since April 1, 2023 and until further notice, Medi-Cal members have 120 days to request a hearing on renewal-related eligibility actions (CDSS). From 2026, federal rules require Medi-Cal managed care plans to decide standard prior approval requests within 7 calendar days.

Law: Stats. 2024, ch. 879; Health & Safety Code 1367.01; Ins. Code 10123.135; 42 CFR 438.210(d)

Questions about appeals in California

How long do I have to appeal a health insurance denial in California?

State law does not set a shorter time. Use the deadline on your denial notice; federal rules give at least 180 days for most plans. You have at least 180 days (about 6 months) from when you receive the denial notice to file an internal appeal.

How do I get an outside (external) review in California?

Independent Medical Review (IMR). For an insurance policy, apply to the CDI online or with the CDI IMR application and attach your insurance card and letters and Explanation of Benefits. For a DMHC-regulated plan, apply to the DMHC: the plan must send you a DMHC IMR application form and an addressed envelope with its grievance decision.

Is outside review free in California?

IMR is free. You pay no application or processing fees.

How long do I have to ask for a Medicaid fair hearing in California?

90 days. The date of the notice of action (the action you disagree with)

Can I keep my Medicaid benefits while I appeal in California?

Your benefits continue while you wait for the hearing (Aid Paid Pending) if you ask for a hearing by the effective date of the change when a 10-day notice is required, or within 10 days of the date of the notice when it is not.

How do I appeal a Marketplace decision in California?

Use the Request for a State Fair Hearing form (online at acms.dss.ca.gov, by fax or mail to the CDSS State Hearings Division, or by phone at 1-800-743-8525). Covered California may first contact you to try to resolve the issue; if not resolved, a CDSS administrative law judge holds a hearing, usually by phone.

Not about a denied claim?

Nearby states

Sources

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