Overview
California law requires health plans to decide prior authorization requests within strict timelines. Standard requests must be decided within 5 business days; urgent requests within 72 hours. Denials must include clinical rationale and inform patients of appeal rights. The California Department of Managed Health Care (DMHC) oversees compliance.
Key Requirements
| Request Type | Deadline | Denial Requirements |
|---|---|---|
| Standard prior auth | 5 business days | Written clinical rationale required |
| Urgent prior auth | 72 hours | Written clinical rationale required |
| Appeal of denial | 5 business days | Independent review available |
- Insurers must acknowledge prior authorization requests within 1 business day.
- Standard requests must be decided within 5 business days of receipt of complete submission.
- Urgent requests must be decided within 72 hours of receipt.
- All denials must include specific clinical rationale and cite plan provisions.
- Patients must be informed of appeal rights and expedited appeal availability in writing.
Penalties and Enforcement
DMHC enforces prior authorization timeline violations with fines and corrective action orders. Failure to provide clinical rationale in denials may result in deemed approval. Plans with systematic violations face license restrictions. DMHC investigates consumer complaints and enforces compliance.
Appeals and Exceptions
Denied prior authorization requests can be appealed within 30 days. Expedited appeals are available for urgent requests. Appeal deadlines are 5 business days, matching initial request timelines. If the plan fails to provide clinical rationale in a denial, the request may be deemed approved.
Interaction with Federal Law
California's prior authorization requirements exceed federal ERISA minimums. Federal law requires decisions within 30 days; California requires 5 business days for most plans. California enforcement is independent and more aggressive.
Common Questions
What is the California prior authorization deadline?
5 business days for standard requests, 72 hours for urgent requests. DMHC enforces timelines with oversight of clinical rationale.
What must California insurers do when denying prior auth?
Provide written clinical rationale, cite plan provisions, inform of appeal rights, and allow expedited appeals.
Track California Prior Authorization Timelines
Altair monitors prior authorization deadlines and enforces clinical documentation standards. See how it works.
State laws change. This reference is current as of 2026-04-06. Consult California insurance regulations or a healthcare attorney for definitive guidance.