If a health insurer denied your claim or prior authorization in California, you have the right to appeal — and the deadlines and protections below are on your side. Here is exactly what applies in California.
The first step is an internal appeal — a formal request asking your insurer to reverse its decision. In California you generally have up to 180 days from the denial date to file it. A strong internal appeal cites your plan's own medical policy, the clinical evidence supporting your treatment, and the specific regulations the insurer must follow.
If the internal appeal is denied, you can escalate to an external review by an Independent Review Organization. California uses , and the reviewer's decision is binding on the insurer. You typically have about 127 days to request it. If your situation is urgent, an expedited review must be completed within 72 hours.
California provides protections beyond the federal minimum that can strengthen your appeal:
Note: Among strongest consumer protections in the country
If your coverage is through a large employer that self-funds its plan, your appeal is governed by federal ERISA law rather than California rules, and some state protections may not apply. Individual, marketplace, small-employer, and government plans are typically state-regulated. CareCost Appeals determines which framework applies from your plan details automatically.
CareCost Appeals generates a formal appeal letter tailored to your denial — citing real clinical evidence, your insurer's own medical policy, and the California and federal rules above — in minutes.