Your Insurance Denied Addiction Treatment in California. What Now?

No. If your plan denies, changes or delays a request for medical services, California law lets you apply to the Department of Managed Health Care for an Independent Medical Review, and if the reviewer overturns the denial the plan is required to authorize the service.

The Department of Managed Health Care, or DMHC, regulates most California health plans, including HMOs and many PPOs, and runs a Help Center for exactly this. A smaller set of plans, mostly certain PPO policies, is regulated by the California Department of Insurance, which runs a parallel review; the DMHC will tell you which applies and redirect you if needed.

The reviewer is an independent medical review organization, not the plan. Its decision on medical necessity binds the plan.

None of this requires a lawyer. The forms are designed for people to complete themselves, and the treatment provider's clinical staff can supply the records that carry most of the weight. Someone else can help you if you sign an authorized assistant form.

What decides most cases is not the argument. It is whether the first step was taken at all.

File a grievance with the plan itself and give it 30 days. The DMHC will close a complaint from anyone who has not first completed the plan's own grievance process, unless the case is urgent.

The member services number on your insurance card is where the grievance is filed, by phone, by mail or on the plan's website. Ask for the grievance to be logged for each specific denial and write down the date and the name of the person who took it.

If the plan does not answer within 30 days, or you are not satisfied with its answer, you can file with the DMHC. If there is a serious threat to your health, you can go to the DMHC immediately without waiting out the 30 days.

Active withdrawal from alcohol or benzodiazepines, or an imminent discharge from a level of care the treating clinician says is still needed, is the kind of situation the expedited route exists for. Say so plainly on the form.

The second thing people assume wrongly is that the state review costs money.

Nothing. The Independent Medical Review is free to the consumer, and the form for the review and for a general complaint against the plan is the same form, submitted online, by mail or by fax.

The reason people do not file is almost never cost. It is that nobody told them the step existed, or the denial letter was read for its reasoning rather than for its deadlines.

The DMHC does not accept additional documents after a complete application is submitted, so gather the denial letter, the clinical records and the treating clinician's letter before filing rather than after.

Knowing the route matters less than knowing what to put in it.

The denial letter, the clinical records supporting medical necessity, and a statement from the treating clinician. The clinical documentation carries the case; your own account of events supports it but rarely decides it.

Ask the treatment provider directly for the records and a letter of medical necessity. Programs handle these routinely and most have someone whose job includes it. If a provider will not help with an appeal, that is worth knowing about the provider.

Address the reason the plan actually gave. Denials usually turn on a specific criterion, that the level of care was not medically necessary or that a lower level had not been tried, and an appeal that argues something else does not engage the decision. In California the plan's criteria for substance use care must follow generally accepted standards, which for level of care means the ASAM Criteria; a clinician letter that speaks in those terms is harder to dismiss.

Keep every letter, note every call with the date and the name, and file complete. An application filed with everything attached moves; one that triggers a request for more information waits.

The review runs on its own clock, which does not pause the clinical situation.

Do not wait for the outcome to seek care. The DMHC says an Independent Medical Review generally takes 45 days from the day the case qualifies, and a general complaint about 30, unless the case is expedited.

Ask the provider whether it will continue treatment pending the review, and what the arrangement is if the review fails. Some will; the terms vary and should be in writing.

In parallel, ask whether another route exists. If you are eligible for Medi-Cal, the county Substance Abuse Service Helpline screens and refers around the clock and operates outside the plan that issued the denial. Two centers in this guide state they accept Medi-Cal.

If the person is in immediate danger, the appeal is not the relevant process. Call 911, or call or text 988. The DMHC Help Center itself is reached on 1-888-466-2219.

Whichever route you take, the questions to ask a provider are the same ones this guide is built around.

• A denial is the first step of a process, not the end of one. California guarantees an Independent Medical Review through the DMHC.
• You must file a grievance with the plan first and give it 30 days, unless the case is urgent.
• The review is free, and the same form covers a review and a general complaint.
• Reviews generally take 45 days; expedited cases are faster.
• An overturned denial requires the plan to authorize the service.

1. California Department of Managed Health Care, Independent Medical Review and Complaint Process. www.dmhc.ca.gov. Read 5 September 2026. The 30-day plan grievance requirement, the 45-day and 30-day handling times, the expedited criteria and the Help Center number are taken from this page.
2. California Department of Insurance, Independent Medical Review. www.insurance.ca.gov. The parallel review route for the minority of California policies regulated by the Department of Insurance rather than the DMHC.

Every figure on this page is resolved from the dataset above at build time rather than typed into the prose, so the number shown and the number published by the source cannot drift apart.