Identify the denial before arguing with it
Obtain the adverse-benefit determination, plan document or evidence of coverage, medical policy, authorization record, claim codes, explanation of benefits, and the complete clinical record. Classify the issue: medical necessity, experimental or investigational treatment, out-of-network access, continuity of care, coding, benefit exclusion, prior authorization, or billing.
Build a deadline chart. The correct regulator and review path can depend on the plan. California Department of Managed Health Care and Department of Insurance processes are not interchangeable, and some employer plans are governed primarily by federal law.
A targeted second opinion should answer the disputed question
The reviewing clinician should receive the relevant records, denial rationale, policy criteria, and a focused question. A useful opinion explains the diagnosis, proposed service, alternatives, urgency, evidence, why the patient meets criteria, and the harm of delay. The clinician—not the law corporation—owns medical judgment and the signed clinical opinion.
Legal counsel can organize the record, identify inconsistencies, frame contractual and procedural issues, prepare a chronology, coordinate evidence, and advocate through an accepted engagement. No outcome can be promised.
Prepare for internal appeal and external review
Most California IMR pathways require a plan grievance or appeal first, with exceptions or accelerated help for urgent threats and certain investigational denials. Submit a complete record because the reviewing agency may limit later additions. Confirm the correct deadline and agency for the specific plan.
- One-page issue statement tied to the exact denial reason.
- Chronology of requests, calls, portal messages, authorizations, denials, and deadlines.
- Relevant clinical records and a focused physician letter—not an undifferentiated chart dump.
- Plan language, medical policy, peer-reviewed support, and network-access evidence.