California external review
California's Independent Medical Review is one of the strongest external review systems in the country. It's free, you don't need a lawyer, decisions bind your health plan — and by DMHC's own 2024 annual report, about 73% of IMR cases end with the enrollee getting the requested service, either because the reviewer overturns the denial or the plan reverses itself first.
Deadlines and decision timelines
- Your filing window: 180 days from the final internal denial.
- Standard review decided in: generally within 45 days of qualification; most decided within 30 days of receiving complete documentation
- Expedited review decided in: about 7 days (3 days for CDI-regulated policies) — imminent and serious threat to your health — severe pain, or potential loss of life, limb, or major bodily function — with written documentation from your doctor
- Cost to you: None — the plan pays the cost of the review
How to file, step by step
- File a grievance with your plan first. Then wait 30 days for its response. Skip the wait entirely if your health is under serious, imminent threat or the denial was experimental/investigational.
- Submit the IMR/Complaint form. One form doubles as the IMR application and a consumer complaint — DMHC routes it correctly. File online at dmhc.ca.gov, or by mail or fax. An Authorized Assistant Form lets someone help you.
- Attach your doctor's support. Medical records and a physician letter matter — the IMR physicians decide on the clinical record. For expedited review, include written documentation of urgency.
- Decision, then coverage within 5 business days. Most IMRs are decided within 30 days of complete documentation. If the denial is overturned, your plan must authorize the service within 5 business days.
Who can use it
- Most Californians: HMO and most Covered California members file with DMHC; a smaller set of CDI-regulated insurance policies file with CDI — and if you pick the wrong agency, they forward it.
- Not eligible: Medicare enrollees, Medi-Cal fee-for-service, members of self-insured employer (ERISA) plans (federal process instead), workers' comp disputes, and pure contract-interpretation disputes.
What to know
- Six months from the plan upholding its denial to file — and the Director can extend for good cause.
- Every IMR decision since 2001 is published (de-identified) — search past decisions for your condition and treatment before writing your grievance.
- The Health Consumer Alliance (1-888-804-3536) provides free help alongside the DMHC Help Center.
- DMHC's 2024 annual report: roughly 73% of IMR cases end with the enrollee receiving the requested service — reversed by the plan or overturned by the reviewer.
California publishes every Independent Medical Review decision. Across 42,749 published decisions (2001–2026), 52.5% ended with the denial overturned or the plan reversing itself. Outcomes for your specific situation: by treatment · by condition.
Source: California DMHC Independent Medical Review outcomes (CHHS Open Data)
Denial data from plans operating in California
| Insurer | Contract / plan | Line | Requests | Denied | Appeals overturned |
|---|---|---|---|---|---|
| Centene | CA-SHP Health Net | Medicaid | 3,096,168 | 2.45% | 39.72% |
| Centene | CA-CalViva Health Net | Medicaid | 310,319 | 6.34% | 48.28% |
| Centene | H3561 Health Net | Medicare Advantage | 290,257 | 1.98% | 77.5% |
| Centene | H0562 Health Net | Medicare Advantage | 184,541 | 1.94% | 77.17% |
| Centene | H5087 Wellcare | Medicare Advantage | 120,425 | 2.8% | 62.79% |
| Centene | CA-ImperialValley Health Net | Medicaid | 57,406 | 7.57% | 48.05% |
| Elevance Health | H4704 Anthem | Medicare Advantage | — | 9.2% | 56% |
| Elevance Health | H8552 Anthem | Medicare Advantage | — | 5% | 84% |
| Elevance Health | CA-Medicaid Anthem | Medicaid | — | 2.6% | 34.1% |
| Elevance Health | H4161 Anthem | Medicare Advantage | — | 2.2% | 85.7% |
| Molina Healthcare | H5810 | Medicare Advantage | — | 2% | 81% |
| Molina Healthcare | H3038 | Medicare Advantage | — | 2% | 52% |
| Molina Healthcare | CA-MEDICAID | Medicaid | — | 2% | 43% |
| Elevance Health | H0544 Anthem | Medicare Advantage | — | 1.6% | 66.7% |
| Molina Healthcare | H5649 | Medicare Advantage | — | 1% | 50% |
| Elevance Health | H4471 Anthem | Medicare Advantage | — | 0.9% | 94.1% |
California external review FAQ
How often do California IMRs succeed?
Per DMHC's 2024 annual report, about 73% of IMR cases end with the enrollee getting the requested service — either the independent reviewer overturns the denial or the plan reverses itself once the IMR is filed. Our published-decision data across 42,000+ IMRs shows similar patterns by treatment and condition.
DMHC or CDI — where do I file?
Most Californians — HMO members and most Covered California enrollees — file with the Department of Managed Health Care. A smaller set of policies regulated by the California Department of Insurance file with CDI (1-800-927-4357). If you file with the wrong agency, they forward your application; don't let the split stop you.
How long do I have to file?
Six months from your plan upholding its denial. You must generally file a grievance with the plan first and give it 30 days — waived when your health is under imminent, serious threat or the denial was experimental/investigational.
What happens if the IMR overturns my denial?
The decision binds your plan: it must authorize the service within 5 business days. IMR decisions are adopted by the state — the plan cannot appeal.
Can I see how similar cases were decided?
Yes. California publishes every IMR decision since 2001, de-identified, on the CHHS Open Data Portal — our treatment and condition pages aggregate all 42,000+ of them so you can see overturn rates for your exact situation.
Primary sources
- DMHC — Independent Medical Review / Complaint process
- Health & Safety Code § 1374.30
- CDI — Independent Medical Review Program
- CHHS Open Data — published IMR determinations