Written by a parent, not a doctor. Nothing here is medical advice.

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California program

Free outside review of a treatment denial (IMR)

A free outside medical review of an eligible health plan’s decision to deny, delay or change care.

What it is

A free outside medical review of an eligible health plan’s decision to deny, delay or change care.

A reviewer outside the plan can reverse the refusal, and the plan has to follow that decision. The review is free; it can also uphold the denial. A denial of experimental treatment such as CAR-T or a trial drug can skip the plan's complaint step and be decided in 7 days.

Who can get it
  • Check the plan document or ask whether DMHC or CDI oversees your plan and whether its review process applies. Private self-funded plans use their federal review route.
  • The ordinary plan complaint step is up to 30 days, or 3 days when expedited. The director may extend the six-month IMR filing window.
  • A qualifying experimental or investigational denial for a life-threatening or seriously debilitating condition can bypass the plan complaint.
What you get
  • No fee for an eligible independent review, with a decision binding on the plan.
  • Standard review in 30 days after complete records, or 3 days when the doctor certifies an imminent threat.
  • An urgent review of an "experimental" denial is decided in about seven days.
What you get
  • A separate experimental-treatment review route, with a seven-day expedited decision period only when its clinical and information requirements are met; obtaining necessary additional information can add up to three days.
If you decide to apply
  1. Ask the social worker to help identify the regulator on your plan document and the right complaint or outside-review form.
  2. Have ready: the denial, treatment date and oncologist’s supporting records. For an experimental denial, check the regulator’s form for the recommendation or evidence route that fits.

1-888-466-2219 DMHC. 1-800-927-4357 CDI · Official page ↗

What happens next
  • Review may uphold or reverse the denial. A reversal binds the plan to cover the reviewed service.
  • If the plan calls a treatment experimental, the oncologist's written recommendation is usually enough to open the review; the regulator's form shows what else can be sent. Urgent cases are decided in about seven days.
Good to know

You have six months after the plan's complaint decision to ask. When waiting would harm your child, the urgent route runs alongside the plan's own complaint; the office named on the denial letter takes the request.

What else to know
  • The plan must notify eligible members about experimental-treatment review within five business days of denial.
  • Some Medi-Cal health-plan disputes can use IMR as well as a state hearing. Each route has its own rules and deadlines. IMR does not extend the hearing deadline; a completed hearing on the same issue can prevent IMR. Ask the Ombudsman or a legal advocate to check the notice, including any separate Medi-Cal Rx route. The Medi-Cal Ombudsman is 888-452-8609. State Hearings is 800-743-8525.
  • The legal insurer matters more than the brand. The plan document identifies DMHC or CDI. Public-employer plans, including CalPERS, require their own terms to be checked.
Official sources
Ask your social worker

“If the plan denies or delays care, could an outside review help, and what are its limits and deadlines? Is it worth requesting, and could you help us find the right route and obtain the oncologist’s support?”

Why I’m asking: I want to know what outside review would be available if a plan denies or delays treatment.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

File the plan complaint, or apply directly to DMHC for a qualifying experimental-treatment denial. Attach the denial and oncologist's letter, and give the treatment date.

Your social worker

The social worker gathers the records and the oncologist's certification. The hospital's approval team often files these.

The care team

The oncologist certifies the life-threatening condition and why the therapy is needed. For the experimental option, two supporting studies or the treating physician's recommendation.

Who decides
An independent review organization for DMHC (or CDI). Its decision binds the plan
Ask your social worker
“Can the oncologist confirm urgency and the approval team request state outside review this week? If the denial says experimental, can we skip the plan complaint?”

How to apply

First step: For an experimental-treatment denial, ask the oncologist to confirm life-threatening illness and apply at dmhc.ca.gov/FileaComplaint. For other denials, complain to the plan first.

  1. Read the denial for the regulator’s name and number.
  2. For experimental denials: ask the oncologist to certify a life-threatening condition and file directly with DMHC.
  3. Otherwise file the plan grievance, then IMR within six months.

Where it starts: dmhc.ca.gov/FileaComplaint (DMHC) or insurance.ca.gov (CDI)

What to gather

  • The denial letter
  • The plan document page naming the regulator
  • The oncologist’s clinical support and the regulator’s required evidence for the applicable experimental-review route; two studies are not required in every route.
  • The treatment date

How long: Ordinary IMR generally takes 30 days after complete records, or 3 days for qualifying urgent review. Expedited experimental review generally takes 7 days after the request and required information, with up to 3 additional days for necessary information.

Clock: six months from the plan's complaint decision to ask DMHC for Independent Medical Review. Urgent within days

What a yes looks like

A written decision overturning the denial. The plan must cover the service.

What a no looks like, and the next move

A decision upholding the plan. Ask the oncologist about a clinical trial or the manufacturer's access program, and the hospital about its financial assistance.

Watch out

  • The plan document names its regulator. DMHC's number is 1-888-466-2219. CDI's number is 1-800-927-4357. CDI covers Anthem Blue Cross Life and Health, Blue Shield of California Life and Health, and Health Net Life. It also covers UnitedHealthcare Insurance Company, Aetna Life, and Cigna Health and Life. Anthem Blue Cross HMO and most PPO products use DMHC.
  • Six months from the plan's complaint decision to apply. The plan's complaint step is capped at 30 days, 3 days if urgent.
  • Self-funded employer plans are outside DMHC and CDI. They use the federal external review through the plan.
  • Some Medi-Cal managed-care disputes can use IMR as well as the state-hearing process. These routes have separate eligibility and timing rules. IMR does not extend the hearing-request deadline, and a completed hearing on the same issue can prevent IMR. The notice, Ombudsman or legal advocate identifies the correct path, including any separate Medi-Cal Rx route. The Medi-Cal Ombudsman is 888-452-8609; State Hearings is 800-743-8525.
  • CalPERS Kaiser’s 2026 plan has its own appeal and fertility-preservation terms. Other CalPERS, school-district and local-government plans need their own document check. Ask the administrator before applying the private self-funded-plan exclusion.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 10, 2026.

What it is worth

Free review binding on the plan: ordinary IMR generally 30 days after records or 3 days urgent; qualifying expedited experimental review 7 days, with up to 3 added days for necessary information.

Legal protection: Independent Medical Review binding on the plan · Experimental/investigational option for life-threatening or seriously debilitating conditions with no plan complaint required · Plan must notify eligible enrollees of the experimental-therapy review within 5 business days of the denial · Open to Medi-Cal members enrolled in a health plan, alongside a state hearing

What it costs the family: No fee.

The eligibility facts, as published

Regulator
DMHC (most HMOs and PPOs; a Medi-Cal beneficiary enrolled in a health care service plan cannot be excluded, HSC 1374.30(f)) or CDI (six named insurers). Self-funded plans excluded
Window
six months from the plan's complaint decision (HSC 1374.30(k)). Director can extend
Grievance step
30 days, 3 days expedited (HSC 1374.30(j)(3))

Decisions this site cannot make: Regulator and jurisdiction · Review eligibility

Expect friction on: Identifying DMHC vs CDI · Records submission

The trap: The plan document names its regulator. DMHC's number is 1-888-466-2219. CDI's number is 1-800-927-4357. CDI covers Anthem Blue Cross Life and Health, Blue Shield of California Life and Health, and Health Net Life. It also covers UnitedHealthcare Insurance Company, Aetna Life, and Cigna Health and Life. Anthem Blue Cross HMO and most PPO products use DMHC.

Where I read this

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