A California health insurer denies a claim for a covered service. Which statement BEST describes the insured's CLAIM-APPEAL rights?

Explanation

Under California Insurance Code §10123.13, §10123.147, and the Fair Claims Settlement Practices Regulations (10 CCR §2695 et seq.), a health insurer that denies a claim must provide a written explanation of the basis for denial, cite the policy provisions relied upon, and inform the insured of internal appeal rights — which is what the response describing written denial notice, internal appeal, and a free Independent Medical Review states. After exhausting the insurer's internal review, the insured may request an Independent Medical Review (IMR) for medical-necessity, investigational/experimental, and certain emergency-care denials. IMRs are administered free of charge by the CDI (for CDI-regulated products) or the DMHC (for Knox-Keene plans), and the insurer is bound by the IMR decision. The response saying the insured has no appeal outside the courts wrongly denies the regulatory appeal scheme. The response letting only the treating physician appeal or request an IMR is wrong; insureds may file directly. The response imposing a 24-hour filing deadline and limiting IMR to group contracts fabricates that deadline; typical appeal windows are 60 to 180 days or longer.