A letter arrives saying the treatment is not medically necessary, or that twelve sessions were enough, or that the plan will not cover the only clinician within forty miles who had an opening. It is written to be final. It is not final. It is the first move in a procedure with deadlines on both sides, and the deadlines on the plan's side are shorter than the one on yours.
The short answer: say the word "grievance" to your plan, which starts a clock of thirty calendar days for a standard case and three calendar days for an urgent one. If the denial is upheld, or thirty days pass with no answer, apply to the Department of Managed Health Care for an Independent Medical Review — free, no lawyer, decided by reviewers who do not work for your plan, and binding on the plan if it goes your way. You have six months from the qualifying event to apply, which is the deadline most people miss because nobody tells them it started. Before any of that, send one sentence asking the plan for the clinical review criteria it used, which California law requires it to give you at no cost.¹ ² ³ ⁴
Before you start: which system is yours
The route depends on who regulates the plan, and the answer is not on your card. One question to member services settles it: "Is this plan regulated by the Department of Managed Health Care, or by the Department of Insurance, or is it a self-funded employer plan?"
| Your plan | Regulator | Where the appeal ends | Phone |
|---|---|---|---|
| HMO, most Blue Shield and Kaiser plans, most Medi-Cal managed care, many PPOs | Department of Managed Health Care | Independent Medical Review | 1-888-466-2219 |
| Some PPO and indemnity plans | California Department of Insurance | CDI's own review programme | 1-800-927-4357 |
| Self-funded employer plan (the employer pays the claims; the insurer only administers) | Federal law, ERISA | Internal appeal, then federal external review | Ask HR for the plan administrator |
| Medi-Cal managed care | DHCS and DMHC | Plan appeal, then State Hearing | Plan's number, then 1-800-743-8525 |
| Medicare Advantage | Federal, CMS | Medicare's own appeal levels | 1-800-633-4227 |
Plan name: · Member ID: · Group #: Regulator confirmed by: (name) on / /
If you are told "self-funded," write it down and go to Step 8. Almost every other step still applies; only the ending changes.
Get the denial in writing, with the reason and the criteria
A denial delivered on the phone is not a document you can appeal. Make it one:
Please send me the denial in writing, including the specific reason for the decision, the name and licence type of the reviewer who made it, and the clinical review criteria applied. Under Health and Safety Code section 1374.721, the plan is required to provide the clinical review criteria at no cost.
That last sentence is the one that changes conversations. California requires plans to conduct utilization review for mental health and substance use disorders using "the criteria and guidelines set forth in the most recent versions of treatment criteria developed by the nonprofit professional association for the relevant clinical specialty," and to provide those criteria and any related training material to providers and enrollees at no cost.³ Once you have the criteria, the appeal stops being an argument about how you feel and becomes a comparison between two documents.
- Date of denial: / / · Reference or claim #:
- Reason as written:
- Criteria requested / / · Received ☐ · Criteria named:
- Reviewer's licence type: (a denial of psychotherapy reviewed by someone outside the specialty is worth naming in the grievance)
Sort the denial into its actual category
Four categories, four different arguments. Tick one.
| ☐ | The denial says | The category | What wins it |
|---|---|---|---|
| ☐ | "Not medically necessary" · "Does not meet criteria" · "Exceeds authorized visits" | A medical necessity dispute | The criteria from Step 1, plus a clinician letter written against them. This is the category Independent Medical Review exists for. |
| ☐ | "Not a covered benefit" · "Excluded under your plan" | A coverage dispute | Your Evidence of Coverage, and the parity statute. The regulator reviews whether the service is a covered benefit before it will send a case to IMR. |
| ☐ | "No in-network provider available" · "Out-of-network not covered" | An access dispute | The timely-access standards, not the necessity criteria. The 10-day rule → |
| ☐ | "Missing information" · "Provider not authorized" · a coding rejection | An administrative dispute | Usually one phone call and a corrected claim. Do this before appealing anything. |
Category chosen:
The second row is worth a sentence of its own. California's parity law requires plans to cover medically necessary treatment for mental health and substance use disorders under the same terms and conditions applied to other medical conditions, and it does not let a plan limit that coverage to short-term or acute treatment; intermediate levels of care — residential treatment, partial hospitalization, intensive outpatient — are inside the requirement.⁴ A plan that calls a residential admission "not a covered benefit" is making a claim you can test.
File the grievance, and say the word
Call member services or use the plan's grievance form online. Use the term; a complaint is not a grievance, and only one of them starts a clock.
I am filing a formal grievance about the denial dated [date], reference [number]. Please confirm the grievance number in writing and send written acknowledgment of receipt. I am also requesting the clinical review criteria applied to this decision under Health and Safety Code section 1374.721.
If waiting would put you at serious risk, say so explicitly, because urgent grievances run on a different clock:
This is an urgent grievance. Delay would pose an imminent and serious threat to my health, specifically: [what would happen].
- Grievance # · Filed / / · Acknowledgment received ☐
- ☐ Standard — the plan's regulation requires procedures that "receive, review and resolve grievances within 30 calendar days of receipt by the plan."¹ Answer due: / /
- ☐ Urgent — the regulation requires a written statement to the Department and to you "on the disposition or pending status of the urgent grievance within three (3) calendar days of receipt of the grievance by the Plan."² Answer due: / /
Get the clinician letter, written against the criteria
One page, from the therapist, prescriber or programme. Ask them to write to the criteria you obtained in Step 1, not in general terms. The letter that works has six parts:
- Diagnosis, and the date it was made.
- The functional problem, in observable terms — what the person cannot currently do that they need to do: work, school, care, sleep, safety.
- What has already been tried, at what intensity, and what happened.
- Why this treatment, at this frequency, at this level of care — quoting the criterion by name.
- What the clinician expects if the treatment does not happen, stated as a clinical prediction rather than a warning.
- The clinician's licence type and number, and a phone number a reviewer can call.
Requested from: on / / · Received ☐ · Attached to grievance ☐
If the treating clinician cannot write it in time, the appeal still proceeds. A letter strengthens it; its absence does not disqualify it.
Keep the log, because the log is the case
Every contact, on one line. This page is what you attach when you escalate.
| Date | Time | Who (name + department) | What was said / decided | Reference # |
|---|---|---|---|---|
Keep every letter and every envelope. Note the postmark date on written denials — the six-month clock in Step 6 is measured from events, and dates you can prove are the ones that count.
Apply for Independent Medical Review
This is the part of the system that most people never reach, and it is free.
When you qualify. All enrollee grievances involving a disputed health care service are eligible for review under the Independent Medical Review System if the requirements of the article are met.⁵ In practice that means you filed a grievance with the plan, and either the decision was upheld or the grievance remains unresolved after thirty days.⁵ For a case that requires expedited review, you are not required to participate in the plan's grievance process for more than three days.⁵
The deadline that gets missed. An enrollee may apply for Independent Medical Review "within six months of any of the qualifying periods or events."⁵ Six months, not thirty days, and not "whenever you get round to it." Write the date the clock started, and the date it runs out, here:
Qualifying event (the denial upheld, or day 31 of an unanswered grievance): / / Six months from that date: / /
How to apply. Online at healthhelp.ca.gov, or by calling the DMHC Help Center at 1-888-466-2219, or on the department's Independent Medical Review Application and Complaint Form. Attach: the denial letter, the grievance and its answer, the clinician letter, the criteria you obtained, and the log from Step 5.
What it costs and what it decides. The department's own consumer materials state that all services are free, that standard reviews are generally determined within forty-five days of the case qualifying, and that if the review is decided in the member's favour the plan must provide the requested service or treatment.⁶
A routing detail worth knowing. If the plan's position is that the service is not covered at all, rather than not medically necessary, the department examines the coverage question first and will tell you if the case does not qualify for Independent Medical Review; it is then handled through the complaint process instead.⁷ You do not choose the track; you file, and the department sorts it. Filing the wrong way is not a mistake you can make here.
- Applied / / · Case # · ☐ standard ☐ expedited
- Decision due (about 45 days for a standard case): / /
While you wait
- Answer the department's requests for documents the same week. Cases stall on unanswered letters more often than on the merits.
- Keep receipts for anything you pay for out of pocket during the dispute; ask for reimbursement as part of the resolution if the decision goes your way.
- Keep going to treatment if you can. A gap in the record is read by reviewers, and not generously.
- If the problem is that nobody in-network has an appointment at all, run the access complaint in parallel rather than instead. It is a different violation with a different remedy. The DMHC complaint worksheet →
If your plan is self-funded, or federal
Self-funded employer plans (ERISA). Federal regulation requires the plan to give you at least 180 days after receiving notice of an adverse benefit determination in which to appeal it.⁸ The plan's own decision deadlines are short: not later than 72 hours for an urgent care claim, 15 days for a pre-service claim, and 30 days for a post-service claim.⁸ On appeal, urgent decisions are due within 72 hours; pre-service within 15 days where there is one level of appeal, or 30 for the first of two; post-service within 30 days, or 60 for the first of two.⁸ After the internal appeals are exhausted, the Affordable Care Act's external review process is the next step; ask the plan administrator in writing for the external review instructions, which the plan is required to provide.
Deadline to appeal (180 days from / / ): / /
Medi-Cal managed care. You have 60 days from the date of the Notice of Action to file an appeal with the plan, and 120 days from the date of the Notice of Appeal Resolution to request a State Hearing; you may also request a State Hearing if you filed an appeal and did not receive a Notice of Appeal Resolution within 30 days.⁹ To keep services going while you appeal, the request generally has to be made within 10 days of the notice, or before the date services are set to stop.⁹
Medicare Advantage. A separate multi-level federal process. Start at 1-800-633-4227 and ask for the plan's appeal instructions in writing.
What happens next
An overturned denial becomes covered care, and the plan is required to provide it. An upheld denial is not the end of the road either: the access route, the parity argument and, for some people, a lawyer, all remain. And a filed case is data. Regulators find plans that deny systematically by looking at the pattern of the cases they receive, which means the tedious afternoon you spent on this is also the reason the next person's denial gets a second look.
The Independent Medical Review, explained end to end → · If your plan is self-funded by your employer → · The ten-day access rule →
Q&A
Q: How do I appeal a therapy denial in California? A: File a formal grievance with the plan, which must resolve it within 30 calendar days for a standard case and report on an urgent one within three.¹ ² If the denial stands, or 30 days pass, apply for a free Independent Medical Review through the DMHC at healthhelp.ca.gov or 1-888-466-2219, within six months of the qualifying event.⁵ ⁶
Q: How long do I really have to file for Independent Medical Review? A: Six months from the qualifying period or event.⁵ People assume it is thirty days, because thirty days is the plan's deadline, not theirs.
Q: Do I need a lawyer? A: No. The department's materials describe the service as free, and the application is a form.⁶ A clinician's letter helps far more than a lawyer's at this stage.
Q: The plan says the treatment is not a covered benefit at all. A: That is a coverage question rather than a necessity question, and the department examines it before deciding whether the case qualifies for Independent Medical Review.⁷ File anyway, and bring the parity argument: plans must cover medically necessary treatment for mental health and substance use disorders under the same terms as other medical conditions, including intermediate levels of care.⁴
Q: What if they cut me off after a set number of sessions? A: A visit limit applied to mental health treatment that is not applied to comparable medical treatment is the classic parity question, and "not medically necessary beyond session twelve" is a medical necessity dispute with a criteria document behind it. Ask for the criteria first.³
Q: Can I appeal for my child? A: Yes, as the enrollee's parent or guardian. Use the same steps and expect to confirm your authority once.
Q: Will appealing get me dropped or flagged? A: Grievances and reviews are a regulated part of the plan's operations; filing one is a use of the plan, not a complaint about it in any sense that touches your coverage.
Our therapist directory: See its current status → · Superbills and out-of-network reimbursement →
Sources
- Cal. Code Regs. tit. 28, §1300.68 — a plan's grievance system must "receive, review and resolve grievances within 30 calendar days of receipt by the plan" — law.cornell.edu.
- Cal. Code Regs. tit. 28, §1300.68.01 — urgent grievances; "a written statement to the Department and the complainant on the disposition or pending status of the urgent grievance within three (3) calendar days of receipt of the grievance by the Plan" — law.cornell.edu.
- California Health and Safety Code §1374.721 — utilization review for mental health and substance use disorders must "apply the criteria and guidelines set forth in the most recent versions of treatment criteria developed by the nonprofit professional association for the relevant clinical specialty," and the plan must "provide, at no cost, the clinical review criteria and any training material or resources to providers and health care service plan enrollees" — california.public.law.
- California Health and Safety Code §1374.72 (SB 855, 2020) — coverage of medically necessary treatment of mental health and substance use disorders "under the same terms and conditions applied to other medical conditions," including intermediate levels of care — california.public.law.
- California Health and Safety Code §1374.30 — "All enrollee grievances involving a disputed health care service are eligible for review under the Independent Medical Review System if the requirements of this article are met"; application "within six months of any of the qualifying periods or events"; grievance filed and "upheld or the grievance remains unresolved after 30 days"; for expedited review, "the enrollee shall not be required to participate in the plan's grievance process for more than three days" — law.justia.com.
- California Department of Managed Health Care, Independent Medical Review fact sheet — "All services are free"; standard reviews generally determined within 45 days; "If an IMR is decided in the member's favor, the health plan must provide the requested health care service or treatment" — dmhc.ca.gov; Help Center, 1-888-466-2219 — dmhc.ca.gov.
- California Department of Managed Health Care, File a Complaint — frequently asked questions, on how a claim that a service is not a covered benefit is examined before a case qualifies for Independent Medical Review — dmhc.ca.gov.
- 29 C.F.R. §2560.503-1 — appeal window "at least 180 days following receipt of a notification of an adverse benefit determination"; initial decision deadlines of 72 hours (urgent care), 15 days (pre-service) and 30 days (post-service); appeal decision deadlines at §2560.503-1(i)(2) — ecfr.gov.
- California Department of Health Care Services, Notice of Action and Notice of Appeal Resolution beneficiary rights attachments — 60 days to file a plan appeal, 120 days to request a State Hearing, aid paid pending within 10 days — dhcs.ca.gov; California Department of Social Services, hearing requests — cdss.ca.gov.
- California Department of Insurance, consumer hotline 1-800-927-4357 and health plan types — insurance.ca.gov.
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