{ "name": "Appealant verified payer appeal-deadline dataset", "description": "Machine-readable table of provider appeal deadlines, dispute-filing windows, and payer response clocks, each value quoted verbatim from a primary source (payer provider manual, state regulation, or federal rule) with the source link and effective date. VERIFIED-PRIMARY rows only.", "license": "https://creativecommons.org/licenses/by/4.0/", "attribution": "Appealant verified payer appeal-deadline dataset. Source: https://www.appealant.com/about-this-data/ . Licensed CC BY 4.0 \u2014 attribute \"Appealant\" with a link back when reused.", "source": "config/deadlines.yaml (VERIFIED-PRIMARY entries only)", "generated": "2026-07-14", "record_count": 79, "records": [ { "payer": "class_commercial_dmhc_hmo", "rule": "provider_dispute_filing_window", "value": "365 calendar days", "day_type": "calendar", "clock_start": "date_of_plan_action_or_inaction_deadline", "direction": "provider", "effective_date": "2004-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "28 CCR \u00a7 1300.71.38(d)(1)", "source_url": "https://www.law.cornell.edu/regulations/california/28-CCR-1300.71.38", "quote": "Neither the plan nor the plan's capitated provider that pays claims, except as required by any state or federal law or regulation, shall impose a deadline for the receipt of a provider dispute for an individual claim, billing dispute or other contractual dispute that is less than 365 days of plan's or the plan's capitated provider's action or, in the case of inaction, that is less than 365 days after the Time for Contesting or Denying Claims has expired." }, { "payer": "class_commercial_dmhc_hmo", "rule": "provider_dispute_acknowledge_electronic", "value": "2 working days", "day_type": "working", "clock_start": "date_of_receipt_of_dispute", "direction": "payer", "effective_date": "2004-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "28 CCR \u00a7 1300.71.38(e)(1)", "source_url": "https://www.law.cornell.edu/regulations/california/28-CCR-1300.71.38", "quote": "(e)(1) In the case of an electronic provider dispute, the acknowledgement shall be provided within two (2) working days of the date of receipt of the electronic provider dispute by the office designated to receive provider disputes" }, { "payer": "class_commercial_dmhc_hmo", "rule": "provider_dispute_acknowledge_paper", "value": "15 working days", "day_type": "working", "clock_start": "date_of_receipt_of_dispute", "direction": "payer", "effective_date": "2004-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "28 CCR \u00a7 1300.71.38(e)(2)", "source_url": "https://www.law.cornell.edu/regulations/california/28-CCR-1300.71.38", "quote": "(e)(2) In the case of a paper provider dispute, the acknowledgement shall be provided within fifteen (15) working days of the date of receipt of the paper provider dispute by the office designated to receive provider disputes." }, { "payer": "class_commercial_dmhc_hmo", "rule": "provider_dispute_resolution_written_determination", "value": "45 working days", "day_type": "working", "clock_start": "date_of_receipt_of_dispute", "direction": "payer", "effective_date": "2004-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "28 CCR \u00a7 1300.71.38(f)", "source_url": "https://www.law.cornell.edu/regulations/california/28-CCR-1300.71.38", "quote": "(f) Time Period for Resolution and Written Determination. The plan or the plan's capitated provider shall resolve each provider dispute or amended provider dispute \u2026 and issue a written determination stating the pertinent facts and explaining the reasons for its determination within 45 working days after the date of receipt of the provider dispute or the amended provider dispute." }, { "payer": "class_commercial_dmhc_hmo", "rule": "prompt_pay_all_plans", "value": "30 calendar days", "day_type": "calendar", "clock_start": "date_of_receipt_of_claim", "direction": "payer", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "Cal. Health & Safety Code \u00a7 1371(a)(1) (operative Jan. 1, 2026)", "source_url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=1371", "quote": "shall reimburse a complete claim or portion thereof, whether in state or out of state, as soon as practicable, but no later than 30 calendar days after receipt" }, { "payer": "class_commercial_dmhc_hmo", "rule": "prompt_pay_interest_rate", "value": "15 percent per annum (interest rate)", "day_type": "N/A", "clock_start": "first_calendar_day_after_30_calendar_day_period", "direction": "payer", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "Cal. Health & Safety Code \u00a7 1371(a)(4) (operative Jan. 1, 2026)", "source_url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=1371", "quote": "interest shall accrue at a rate of 15 percent per annum beginning with the first calendar day after the 30-calendar-day period" }, { "payer": "class_commercial_dmhc_hmo", "rule": "medical_necessity_um_appeal_to_plan", "value": "60 working days", "day_type": "working", "clock_start": "capitated_provider_date_of_determination", "direction": "provider", "effective_date": "2004-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "28 CCR \u00a7 1300.71(e)(5) (DMHC AB1455 Full Regulation text)", "source_url": "https://www.blueshieldca.com/content/dam/bsca/en/provider/documents/2024/guidelines-resources/PRV_AB1455_Full_Regulation.pdf", "quote": "The plan's contract with a capitated provider shall provide that any provider that submits a claim dispute to the plan's capitated provider's dispute resolution mechanism(s) involving an issue of medical necessity or utilization review shall have an unconditional right of appeal for that claim dispute to the plan's dispute resolution process for a de novo review and resolution for a period of 60 working days from the capitated provider's Date of Determination, pursuant to the provisions of section 1300.71.38(a)(4) of title 28." }, { "payer": "class_commercial_cdi_ppo", "rule": "prompt_pay_insurer", "value": "30 calendar days", "day_type": "calendar", "clock_start": "date_of_receipt_of_claim", "direction": "payer", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "Cal. Ins. Code \u00a7 10123.13 (operative Jan. 1, 2026)", "source_url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=INS§ionNum=10123.13", "quote": "reimburse a complete claim or portion thereof \u2026 no later than 30 calendar days after receipt of the claim by the insurer" }, { "payer": "class_commercial_cdi_ppo", "rule": "prompt_pay_interest_rate_insurer", "value": "15 percent per annum (interest rate)", "day_type": "N/A", "clock_start": "first_calendar_day_after_30_calendar_day_period", "direction": "payer", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "Cal. Ins. Code \u00a7 10123.13 (operative Jan. 1, 2026)", "source_url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=INS§ionNum=10123.13", "quote": "interest shall accrue at the rate of 15 percent per annum beginning with the first calendar day after the 30-calendar-day period" }, { "payer": "class_commercial_cdi_ppo", "rule": "provider_dispute_determination_cdi", "value": "45 working days", "day_type": "working", "clock_start": "date_of_receipt_of_dispute", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Cal. Ins. Code \u00a7 10123.137", "source_url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=INS§ionNum=10123.137", "quote": "dispute mechanism required for contracted and non-contracted providers; written determination within 45 working days; no 365-day floor on the CDI side (contrast 28 CCR \u00a7 1300.71.38(d)(1) on the DMHC side)" }, { "payer": "class_erisa_self_funded", "rule": "appeal_level_1_filing", "value": "180 calendar days", "day_type": "calendar", "clock_start": "receipt_of_adverse_benefit_determination_notice", "direction": "provider", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "29 CFR \u00a7 2560.503-1(h)(3)(i)", "source_url": "https://www.law.cornell.edu/cfr/text/29/2560.503-1", "quote": "(h)(3)(i) Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination" }, { "payer": "class_erisa_self_funded", "rule": "full_and_fair_review_independent_reviewer", "value": "\u2014 (procedural rule, no numeric deadline)", "day_type": "N/A", "clock_start": "N/A", "direction": "payer", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "29 CFR \u00a7 2560.503-1(h)(3)(ii)", "source_url": "https://www.law.cornell.edu/cfr/text/29/2560.503-1", "quote": "(h)(3)(ii) Provide for a review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the plan who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual" }, { "payer": "class_erisa_self_funded", "rule": "medical_judgment_consultation", "value": "\u2014 (procedural rule, no numeric deadline)", "day_type": "N/A", "clock_start": "N/A", "direction": "payer", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "29 CFR \u00a7 2560.503-1(h)(3)(iii)", "source_url": "https://www.law.cornell.edu/cfr/text/29/2560.503-1", "quote": "(h)(3)(iii) Provide that, in deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment" }, { "payer": "class_erisa_self_funded", "rule": "deemed_exhaustion", "value": "\u2014 (procedural rule, no numeric deadline)", "day_type": "N/A", "clock_start": "N/A", "direction": "payer", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "29 CFR \u00a7 2560.503-1(l)(1)", "source_url": "https://www.law.cornell.edu/cfr/text/29/2560.503-1", "quote": "(l)(1) In the case of the failure of a plan to establish or follow claims procedures consistent with the requirements of this section, a claimant shall be deemed to have exhausted the administrative remedies available under the plan and shall be entitled to pursue any available remedies under section 502(a) of the Act on the basis that the plan has failed to provide a reasonable claims procedure that would yield a decision on the merits of the claim." }, { "payer": "class_erisa_self_funded", "rule": "urgent_expedited_review", "value": "\u2014 (procedural rule, no numeric deadline)", "day_type": "N/A", "clock_start": "N/A", "direction": "payer", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "29 CFR \u00a7 2560.503-1(h)(3)(vi)", "source_url": "https://www.law.cornell.edu/cfr/text/29/2560.503-1", "quote": "(h)(3)(vi) Provide, in the case of a claim involving urgent care, for an expedited review process pursuant to which (A) A request for an expedited appeal of an adverse benefit determination may be submitted orally or in writing by the claimant; and (B) All necessary information, including the plan's benefit determination on review, shall be transmitted between the plan and the claimant by telephone, facsimile, or other available similarly expeditious method." }, { "payer": "class_medicare_advantage", "rule": "level_1_reconsideration_filing", "value": "60 calendar days", "day_type": "calendar", "clock_start": "receipt_of_written_organization_determination_notice", "direction": "provider", "effective_date": "2025-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.582(b)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.582", "quote": "a request for reconsideration must be filed within 60 calendar days after receipt of the written organization determination notice." }, { "payer": "class_medicare_advantage", "rule": "level_1_reconsideration_receipt_presumption", "value": "5 calendar days", "day_type": "calendar", "clock_start": "date_on_written_organization_determination", "direction": "provider", "effective_date": "2025-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.582(b)(1)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.582", "quote": "The date of receipt of the organization determination is presumed to be 5 calendar days after the date of the written organization determination, unless there is evidence to the contrary." }, { "payer": "class_medicare_advantage", "rule": "level_1_standard_decision_services", "value": "30 calendar days", "day_type": "calendar", "clock_start": "receipt_of_reconsideration_request", "direction": "payer", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.590(a)(1)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.590", "quote": "no later than 30 calendar days from the date it receives the request for a standard reconsideration" }, { "payer": "class_medicare_advantage", "rule": "level_1_standard_decision_payment", "value": "60 calendar days", "day_type": "calendar", "clock_start": "receipt_of_reconsideration_request", "direction": "payer", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.590(b)(1)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.590", "quote": "no later than 60 calendar days from the date it receives the request for a standard reconsideration" }, { "payer": "class_medicare_advantage", "rule": "level_1_part_b_drug_decision", "value": "7 calendar days", "day_type": "calendar", "clock_start": "receipt_of_reconsideration_request", "direction": "payer", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.590(c)(1)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.590", "quote": "no later than 7 calendar days from the date it receives the request for a standard reconsideration. This 7 calendar-day period may not be extended" }, { "payer": "class_medicare_advantage", "rule": "level_1_expedited_decision", "value": "72 hours", "day_type": "hours", "clock_start": "receipt_of_expedited_request", "direction": "payer", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.590(e)(1)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.590", "quote": "no later than 72 hours after receiving the request" }, { "payer": "class_medicare_advantage", "rule": "level_1_extension", "value": "14 calendar days", "day_type": "calendar", "clock_start": "original_deadline", "direction": "payer", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.590(f)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.590", "quote": "the MA organization may extend the standard or expedited reconsideration deadline for services by up to 14 calendar days if\u2026" }, { "payer": "class_medicare_advantage", "rule": "level_2_ire_review", "value": "30 calendar days", "day_type": "calendar", "clock_start": "date_ire_receives_case_file", "direction": "payer", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.592(b) + Maximus Part C IRE Reconsideration Process Manual (Rev. 2024), \u00a7 6.1", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.592", "quote": "Maximus is responsible for completing the IRE reconsideration within the same timeframes and standards that apply to Medicare Health Plans." }, { "payer": "class_medicare_advantage", "rule": "level_3_alj_filing", "value": "60 calendar days", "day_type": "calendar", "clock_start": "receipt_of_ire_reconsidered_determination_notice", "direction": "provider", "effective_date": "2002-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.602(b)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.602", "quote": "a party must file a request for a hearing within 60 calendar days of receipt of the notice of a reconsidered determination\u2026 the date of receipt of the reconsideration is presumed to be 5 calendar days after the date of the notice of the reconsidered determination, unless there is evidence to the contrary." }, { "payer": "class_medicare_advantage", "rule": "level_3_alj_aic_threshold_2026", "value": "200 (dollars \u2014 amount-in-controversy threshold, not a deadline)", "day_type": "dollars", "clock_start": "N/A", "direction": "provider", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "90 FR 55869 (Dec. 4, 2025) \u2014 CY 2026 AIC Threshold", "source_url": "https://www.federalregister.gov/documents/2025/12/04/2025-21879/medicare-program-medicare-appeals-adjustment-to-the-amount-in-controversy-threshold-amounts-for", "quote": "The CY 2026 AIC threshold amount for ALJ hearings is $200.00\u2026 effective for requests for ALJ hearings and judicial review filed on or after January 1, 2026." }, { "payer": "class_medicare_advantage", "rule": "pa_standard_decision_2026", "value": "7 calendar days", "day_type": "calendar", "clock_start": "receipt_of_pa_request", "direction": "payer", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.568(b)(1)(ii) (CMS-0057-F) + CMS-0057-F fact sheet", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.568", "quote": "7 calendar days after receiving the request" }, { "payer": "class_medicare_advantage", "rule": "organization_determination_standard_non_pa", "value": "14 calendar days", "day_type": "calendar", "clock_start": "receipt_of_request", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.568(b)(1)(i)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.568", "quote": "42 CFR 422.568(b)(1): standard organization determinations \u2014 (i) items/services not subject to prior authorization: 14 calendar days" }, { "payer": "class_medi_cal_managed_care", "rule": "mco_appeal_filing", "value": "60 calendar days", "day_type": "calendar", "clock_start": "date_on_adverse_benefit_determination_notice", "direction": "provider", "effective_date": "2016-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 438.402(c)(2)(ii)", "source_url": "https://www.law.cornell.edu/cfr/text/42/438.402", "quote": "an enrollee has 60 calendar days from the date on the adverse benefit determination notice in which to file a request for an appeal" }, { "payer": "class_medi_cal_managed_care", "rule": "mco_standard_resolution", "value": "30 calendar days", "day_type": "calendar", "clock_start": "receipt_of_appeal", "direction": "payer", "effective_date": "2016-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 438.408(b)(2) + DHCS APL 21-011", "source_url": "https://www.law.cornell.edu/cfr/text/42/438.408", "quote": "the State must establish a timeframe that is no longer than 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal." }, { "payer": "class_medi_cal_managed_care", "rule": "mco_expedited_resolution", "value": "72 hours", "day_type": "hours", "clock_start": "receipt_of_expedited_appeal", "direction": "payer", "effective_date": "2016-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 438.408(b)(3)", "source_url": "https://www.law.cornell.edu/cfr/text/42/438.408", "quote": "the State must establish a timeframe that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal." }, { "payer": "class_medi_cal_managed_care", "rule": "mco_extension", "value": "14 calendar days", "day_type": "calendar", "clock_start": "original_deadline", "direction": "payer", "effective_date": "2016-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 438.408(c)(1)", "source_url": "https://www.law.cornell.edu/cfr/text/42/438.408", "quote": "The MCO, PIHP, or PAHP may extend the timeframes from paragraph (b) of this section by up to 14 calendar days if\u2014" }, { "payer": "class_medi_cal_managed_care", "rule": "continuation_of_benefits_request", "value": "10 calendar days", "day_type": "calendar", "clock_start": "later_of_plan_sending_abd_notice_or_intended_effective_date_of_action", "direction": "provider", "effective_date": "2016-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 438.420(a) (\"timely files\" definition)", "source_url": "https://www.law.cornell.edu/cfr/text/42/438.420", "quote": "'Timely files' means files for continuation of benefits on or before the later of the following: (i) Within 10 calendar days of the MCO, PIHP, or PAHP sending the notice of adverse benefit determination. (ii) The intended effective date of the MCO's, PIHP's, or PAHP's proposed adverse benefit determination." }, { "payer": "class_medi_cal_managed_care", "rule": "deemed_exhaustion_mco_timing_failure", "value": "\u2014 (procedural rule, no numeric deadline)", "day_type": "N/A", "clock_start": "N/A", "direction": "payer", "effective_date": "2016-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 438.402(c)(1)(i)(A)", "source_url": "https://www.law.cornell.edu/cfr/text/42/438.402", "quote": "In the case of an MCO, PIHP, or PAHP that fails to adhere to the notice and timing requirements in \u00a7 438.408, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process." }, { "payer": "class_medi_cal_managed_care", "rule": "standard_authorization_decision", "value": "7 calendar days", "day_type": "calendar", "clock_start": "receipt_of_service_request", "direction": "payer", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 438.210(d)(1)(i) (as amended by CMS-0057-F, 89 FR 8980)", "source_url": "https://www.law.cornell.edu/cfr/text/42/438.210", "quote": "may not exceed 7 calendar days after receiving the request" }, { "payer": "class_medi_cal_managed_care", "rule": "expedited_authorization_decision", "value": "72 hours", "day_type": "hours", "clock_start": "receipt_of_service_request", "direction": "payer", "effective_date": "2016-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 438.210(d)(2)(i)", "source_url": "https://www.law.cornell.edu/cfr/text/42/438.210", "quote": "no later than 72 hours after receipt of the request for service" }, { "payer": "class_medi_cal_managed_care", "rule": "state_fair_hearing_filing", "value": "120 calendar days", "day_type": "calendar", "clock_start": "date_of_notice_of_appeal_resolution", "direction": "provider", "effective_date": "2016-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 438.408(f)(2) + DHCS APL 21-011", "source_url": "https://www.law.cornell.edu/cfr/text/42/438.408", "quote": "The enrollee must have no less than 90 calendar days and no more than 120 calendar days from the date of the MCO's, PIHP's, or PAHP's notice of resolution to request a State fair hearing." }, { "payer": "class_medi_cal_managed_care", "rule": "advance_notice_termination_reduction", "value": "10 calendar days", "day_type": "calendar", "clock_start": "counts_backward_from_intended_date_of_action", "direction": "payer", "effective_date": "2016-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 431.211 (via \u00a7 438.404(c)(1) cross-reference)", "source_url": "https://www.law.cornell.edu/cfr/text/42/431.211", "quote": "The State or local agency must send a notice at least 10 days before the date of action, except as permitted under \u00a7\u00a7 431.213 and 431.214." }, { "payer": "UHC", "rule": "commercial_claim_submission", "value": "90 calendar days \u2014 contractual floor; confirm the limit in your participation agreement", "day_type": "calendar", "clock_start": "date_of_service", "direction": "provider", "effective_date": "2026-04-01", "verification": "VERIFIED-PRIMARY", "source_title": "2026 UHC Administrative Guide, p. 206 (capitation/delegation supplement)", "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/2026-UHC-Administrative-Guide.pdf", "quote": "For commercial claims, submit clean claims per the time frame listed in your Agreement or per applicable laws. We, or our capitated care provider, allow at least 90 days for participating health care providers. For commercial plans, we allow up to 180 days for nonparticipating health care providers from the date of service to submit claims." }, { "payer": "UHC", "rule": "commercial_reconsideration_and_appeal_combined_window", "value": "12 months", "day_type": "months", "clock_start": "date_of_original_claim_eob_or_pra", "direction": "provider", "effective_date": "2026-04-01", "verification": "VERIFIED-PRIMARY", "source_title": "2026 UHC Administrative Guide, Ch. 10, p. 134", "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/2026-UHC-Administrative-Guide.pdf", "quote": "You must submit your reconsideration and appeal to us within 12 months from the date of the original claim EOB or PRA (or as required by law or your Agreement)." }, { "payer": "UHC", "rule": "ca_commercial_hmo_pdr_filing", "value": "365 calendar days", "day_type": "calendar", "clock_start": "date_of_adverse_payment_determination", "direction": "provider", "effective_date": "2026-04-01", "verification": "VERIFIED-PRIMARY", "source_title": "2026 UHC Administrative Guide, p. 449 (UHC West supplement)", "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/2026-UHC-Administrative-Guide.pdf", "quote": "All disputes must be submitted within 365 calendar days following the date of the adverse payment determination on the claim, unless your Agreement or state law dictate otherwise." }, { "payer": "UHC", "rule": "ma_claim_submission", "value": "365 calendar days \u2014 contractual floor; confirm the limit in your participation agreement", "day_type": "calendar", "clock_start": "through_date_of_service", "direction": "provider", "effective_date": "2026-04-01", "verification": "VERIFIED-PRIMARY", "source_title": "2026 UHC Administrative Guide, p. 206", "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/2026-UHC-Administrative-Guide.pdf", "quote": "For MA plans, we are required to allow 365 days from the through date of service for noncontracted health care providers to submit claims for processing." }, { "payer": "UHC", "rule": "ma_reconsideration_filing", "value": "60 calendar days", "day_type": "calendar", "clock_start": "date_of_coverage_denial_notice", "direction": "provider", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "UHC MA Non-Contracted Care Provider Dispute and Appeal Rights (PCA-1-24-03448)", "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/health-plans/medicare/MA-Non-Cont-Provider-Dispute-Appeal-Rights.pdf", "quote": "If you disagree with a denied claim or if we paid for a different service or level of service than what was billed, you have 60 days from the denial date to file a payment reconsideration (appeal) request." }, { "payer": "UHC", "rule": "ma_noncontracted_claim_payment_dispute", "value": "120 calendar days", "day_type": "calendar", "clock_start": "date_of_initial_payment", "direction": "provider", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "UHC MA Non-Contracted Care Provider Dispute and Appeal Rights (PCA-1-24-03448)", "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/health-plans/medicare/MA-Non-Cont-Provider-Dispute-Appeal-Rights.pdf", "quote": "You must file a dispute within 120 calendar days from the initial payment." }, { "payer": "UHC", "rule": "corrected_claim", "value": "90 calendar days \u2014 contractual floor; confirm the limit in your participation agreement", "day_type": "calendar", "clock_start": "date_of_service", "direction": "provider", "effective_date": "2026-04-01", "verification": "VERIFIED-PRIMARY", "source_title": "2026 UHC Administrative Guide, Ch. 10, pp. 144-145", "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/2026-UHC-Administrative-Guide.pdf", "quote": "Your Agreement requires that all information necessary to process a claim must be received by UnitedHealthcare within a specified number of days from the date of service \u2026 This number of days also applies to submission of corrected claims. For example, if the last date of service provided is May 1, and the timely filing limit in your participation agreement is 90 days, all information necessary to process the claim, including any corrections, must be received by UnitedHealthcare no later than 90 days after May 1." }, { "payer": "UHC", "rule": "ca_commercial_hmo_pdr_determination", "value": "45 business days", "day_type": "business", "clock_start": "receipt_of_dispute", "direction": "payer", "effective_date": "2026-04-01", "verification": "VERIFIED-PRIMARY", "source_title": "2026 UHC Administrative Guide, p. 450 (UHC West PDR reference table)", "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/2026-UHC-Administrative-Guide.pdf", "quote": "UnitedHealthcare acknowledges receipt of paper disputes within 15 business days and within 2 business days for electronic disputes. If additional information is required, the dispute is returned within 45 business days. A written determination is issued within 45 business days." }, { "payer": "UHC", "rule": "ma_noncontracted_payment_dispute_response", "value": "30 calendar days", "day_type": "calendar", "clock_start": "receipt_of_payment_dispute_request", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "UHC MA Non-Contracted Care Provider Dispute and Appeal Rights (PCA-1-24-03448)", "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/health-plans/medicare/MA-Non-Cont-Provider-Dispute-Appeal-Rights.pdf", "quote": "UnitedHealthcare Medicare Advantage has 30 calendar days to review and respond after receiving a payment dispute request." }, { "payer": "UHC", "rule": "ma_noncontracted_appeal_response", "value": "60 calendar days", "day_type": "calendar", "clock_start": "receipt_of_completed_payment_reconsideration_request", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "UHC MA Non-Contracted Care Provider Dispute and Appeal Rights (PCA-1-24-03448)", "source_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/health-plans/medicare/MA-Non-Cont-Provider-Dispute-Appeal-Rights.pdf", "quote": "UnitedHealthcare Medicare Advantage has 60 calendar days to review and respond after receiving a completed payment reconsideration (appeal) request. If the plan upholds all or part of the initial payment determination, we must forward the case to the CMS Independent Review Entity (IRE) for a second-level review." }, { "payer": "Anthem_Blue_Cross_CA", "rule": "medi_cal_claim_reconsideration_filing", "value": "12 months", "day_type": "months", "clock_start": "last_action_on_claim", "direction": "provider", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "2026 Anthem CA Medicaid Provider Manual, \"Claim Payment Reconsiderations\", pp. 228-229", "source_url": "https://providers.anthem.com/docs/gpp/california-provider/CA_CAID_ProviderManual.pdf", "quote": "We must receive your request for reconsideration within 12 months of the last action on a claim." }, { "payer": "Anthem_Blue_Cross_CA", "rule": "medi_cal_claim_payment_appeal_filing", "value": "60 calendar days", "day_type": "calendar", "clock_start": "reconsideration_outcome", "direction": "provider", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "2026 Anthem CA Medicaid Provider Manual, \"Claim Payment Appeal\", p. 229", "source_url": "https://providers.anthem.com/docs/gpp/california-provider/CA_CAID_ProviderManual.pdf", "quote": "If you are unsatisfied with the outcome of the reconsideration, you may submit a claim payment appeal within 60 calendar days of the reconsideration outcome." }, { "payer": "Anthem_Blue_Cross_CA", "rule": "commercial_provider_dispute_filing", "value": "365 calendar days", "day_type": "calendar", "clock_start": "date_on_notice_of_action_letter", "direction": "provider", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Anthem CA Claims Submissions and Disputes (live page)", "source_url": "https://providers.anthem.com/california-provider/claims/claims-submissions-and-disputes", "quote": "The appeal must be received by Anthem Blue Cross (Anthem) within 365 days from the date on the notice of the letter advising of the action." }, { "payer": "Anthem_Blue_Cross_CA", "rule": "medi_cal_reconsideration_response", "value": "30 calendar days", "day_type": "calendar", "clock_start": "receipt_of_reconsideration_request", "direction": "payer", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "2026 Anthem CA Medicaid Provider Manual, p. 229", "source_url": "https://providers.anthem.com/docs/gpp/california-provider/CA_CAID_ProviderManual.pdf", "quote": "The results will then be communicated to you in a determination letter within 30 calendar days of the receipt of the reconsideration." }, { "payer": "Anthem_Blue_Cross_CA", "rule": "commercial_pdr_response", "value": "45 business days", "day_type": "business", "clock_start": "receipt_of_dispute", "direction": "payer", "effective_date": "2022-12-01", "verification": "VERIFIED-PRIMARY", "source_title": "Anthem CA \"Key Steps to Provider Dispute Resolution\" (SEM, Dec 2022)", "source_url": "https://www.anthembluecross.com/content/dam/digital/docs/anthembluecross/provider/commercial/general/CA_SEM_00011.pdf", "quote": "Tracking records are assigned to G&A for review to be completed within 45 business days of receipt." }, { "payer": "Anthem_Blue_Cross_CA", "rule": "medi_cal_appeal_response", "value": "30 calendar days", "day_type": "calendar", "clock_start": "receipt_of_claim_payment_appeal", "direction": "payer", "effective_date": "2026-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "2026 Anthem CA Medicaid Provider Manual, pp. 229-230", "source_url": "https://providers.anthem.com/docs/gpp/california-provider/CA_CAID_ProviderManual.pdf", "quote": "The results will then be communicated to you in a determination letter within 30 calendar days of the receipt of the claim payment appeal." }, { "payer": "Anthem_Blue_Cross_CA", "rule": "submission_channel_preferred", "value": "\u2014 (procedural rule, no numeric deadline)", "day_type": "N/A", "clock_start": "N/A", "direction": "provider", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Anthem CA Claims Submissions and Disputes (live page)", "source_url": "https://providers.anthem.com/california-provider/claims/claims-submissions-and-disputes", "quote": "Anthem uses Availity, a secure, full-service web portal... Use Availity to submit claims, check the status of claims, appeal a claim decision and much more." }, { "payer": "Blue_Shield_of_CA", "rule": "provider_dispute_filing", "value": "365 calendar days", "day_type": "calendar", "clock_start": "date_of_plan_action_or_inaction", "direction": "provider", "effective_date": "2004-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "BSCA AB 1455 Provider Claims & Dispute Resolution Summary, p. 5", "source_url": "https://www.blueshieldca.com/content/dam/bsca/en/provider/documents/2024/guidelines-resources/PRV_AB1455_reg_sum.pdf", "quote": "Must give provider at least 365 days to submit an appeal." }, { "payer": "Blue_Shield_of_CA", "rule": "provider_dispute_acknowledge_electronic", "value": "2 business days", "day_type": "business", "clock_start": "date_of_receipt", "direction": "payer", "effective_date": "2004-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "BSCA AB 1455 Summary, p. 5", "source_url": "https://www.blueshieldca.com/content/dam/bsca/en/provider/documents/2024/guidelines-resources/PRV_AB1455_reg_sum.pdf", "quote": "Must acknowledge receipt of a provider appeal: within 2 business days for appeals submitted electronically and within 15 working days for appeals submitted in paper form." }, { "payer": "Blue_Shield_of_CA", "rule": "provider_dispute_acknowledge_paper", "value": "15 working days", "day_type": "working", "clock_start": "date_of_receipt", "direction": "payer", "effective_date": "2004-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "BSCA AB 1455 Summary, p. 5", "source_url": "https://www.blueshieldca.com/content/dam/bsca/en/provider/documents/2024/guidelines-resources/PRV_AB1455_reg_sum.pdf", "quote": "...within 15 working days for appeals submitted in paper form." }, { "payer": "Blue_Shield_of_CA", "rule": "provider_dispute_resolution", "value": "45 working days", "day_type": "working", "clock_start": "date_of_receipt_of_dispute", "direction": "payer", "effective_date": "2004-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "BSCA AB 1455 Summary, p. 5", "source_url": "https://www.blueshieldca.com/content/dam/bsca/en/provider/documents/2024/guidelines-resources/PRV_AB1455_reg_sum.pdf", "quote": "Must resolve appeals in accordance with claims timeliness requirements (30/45 working days) and must send written determination on the appeal within 45 working days." }, { "payer": "Blue_Shield_of_CA", "rule": "ma_member_grievance_resolution", "value": "30 calendar days", "day_type": "calendar", "clock_start": "receipt_of_grievance", "direction": "payer", "effective_date": "2026-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "BSCA Independent Physician and Provider (IPP) Manual, July 2026 edition, p. 29", "source_url": "https://www.blueshieldca.com/content/dam/bsca/en/provider/docs/7-26-A11421-IPP-Manual.pdf", "quote": "The complaint will be resolved within 30 calendar days of receipt." }, { "payer": "Blue_Shield_of_CA", "rule": "ma_post_service_claim_appeal_resolution", "value": "60 calendar days", "day_type": "calendar", "clock_start": "receipt_of_appeal", "direction": "payer", "effective_date": "2026-07-01", "verification": "VERIFIED-PRIMARY", "source_title": "BSCA IPP Manual, July 2026 edition, p. 29", "source_url": "https://www.blueshieldca.com/content/dam/bsca/en/provider/docs/7-26-A11421-IPP-Manual.pdf", "quote": "Post-service appeals (claims) are resolved within 60 days." }, { "payer": "Aetna_CA", "rule": "reconsideration_filing", "value": "180 calendar days", "day_type": "calendar", "clock_start": "date_of_initial_claim_decision", "direction": "provider", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Aetna Disputes & Appeals Overview (aetna.com)", "source_url": "https://www.aetna.com/health-care-professionals/disputes-appeals/disputes-appeals-overview.html", "quote": "You need to file your reconsideration within 180 calendar days of the initial claim decision." }, { "payer": "Aetna_CA", "rule": "ca_hmo_provider_dispute_filing", "value": "365 calendar days", "day_type": "calendar", "clock_start": "date_of_initial_claim_decision", "direction": "provider", "effective_date": "2004-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "Aetna provider appeals \u2014 state exceptions page (aetna.com)", "source_url": "https://www.aetna.com/health-care-professionals/disputes-appeals/provider-appeals.html", "quote": "California (CA) HMO \u2014 All providers, participating and nonparticipating, when the request relates to an HMO member and the date of service is on/after 1/1/04 \u2014 365 days" }, { "payer": "Aetna_CA", "rule": "appeal_filing", "value": "60 calendar days", "day_type": "calendar", "clock_start": "date_of_reconsideration_decision", "direction": "provider", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Aetna Disputes & Appeals Overview (aetna.com)", "source_url": "https://www.aetna.com/health-care-professionals/disputes-appeals/disputes-appeals-overview.html", "quote": "File your appeal within 60 calendar days of the reconsideration decision." }, { "payer": "Aetna_CA", "rule": "reconsideration_response_standard", "value": "30 business days", "day_type": "business", "clock_start": "receipt_of_reconsideration_request", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Aetna Disputes & Appeals Overview (aetna.com)", "source_url": "https://www.aetna.com/health-care-professionals/disputes-appeals/disputes-appeals-overview.html", "quote": "Response times vary. It depends on the request and whether a specialty unit needs to review it. In most cases, you'll receive an EOB or letter within 30 business days of us receiving the request." }, { "payer": "Aetna_CA", "rule": "appeal_response", "value": "60 business days", "day_type": "business", "clock_start": "receipt_of_appeal_or_requested_additional_information", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Aetna Disputes & Appeals Overview (aetna.com)", "source_url": "https://www.aetna.com/health-care-professionals/disputes-appeals/disputes-appeals-overview.html", "quote": "We'll send a decision by mail or fax within 60 business days of receiving your appeal \u2014 or of receiving any additional information we request." }, { "payer": "Cigna_CA", "rule": "commercial_in_network_claim_submission", "value": "90 calendar days \u2014 contractual floor; confirm the limit in your participation agreement", "day_type": "calendar", "clock_start": "date_of_service", "direction": "provider", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Cigna \"When to File\" (static.cigna.com)", "source_url": "https://static.cigna.com/assets/chcp/resourceLibrary/clinicalReimbursementPayment/medicalClinicalReimburseWhenToFile.html", "quote": "Cigna will consider: Participating provider claims submitted three (3) months [90 days] after the date of service; OR out-of-network claims submitted six (6) months [180 days] after the date of service. If services are rendered on consecutive days, such as for a hospital confinement, the limit will be counted from the last date of service." }, { "payer": "Cigna_CA", "rule": "ca_provider_dispute_filing", "value": "365 calendar days", "day_type": "calendar", "clock_start": "date_of_initial_payment_or_denial_notice_or_adjustment", "direction": "provider", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Cigna California Dispute Resolution Policy", "source_url": "https://www.cigna.com/health-care-providers/coverage-and-claims/appeals-disputes/california-provider", "quote": "To initiate a dispute, health care providers in California must submit their request in writing within 365 calendar days from the date of the initial payment or denial notice, or if the appeal relates to an adjusted payment, within 365 calendar days from the date of the adjustment." }, { "payer": "Cigna_CA", "rule": "commercial_level_1_appeal", "value": "180 calendar days", "day_type": "calendar", "clock_start": "date_of_initial_payment_or_denial_decision", "direction": "provider", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Cigna Appeal Policy and Procedures for Health Care Professionals", "source_url": "https://static.cigna.com/assets/chcp/resourceLibrary/clinicalReimbursementPayment/medicalClinicalReimbursePoliciesProcedures.html", "quote": "In general, the Single Level of the health care professional payment review process must be initiated in writing within 180 calendar days from the date of the initial payment or denial decision from Cigna." }, { "payer": "Cigna_CA", "rule": "california_hmo_pos_acknowledge", "value": "15 business days", "day_type": "business", "clock_start": "receipt_of_dispute", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Cigna California Dispute Resolution Policy", "source_url": "https://www.cigna.com/health-care-providers/coverage-and-claims/appeals-disputes/california-provider", "quote": "Cigna Healthcare will send a letter acknowledging a California HMO and POS dispute within 15 business days of receipt by the P.O. Box designated to receive Cigna HealthCare of California, Inc. health care provider disputes." }, { "payer": "Cigna_CA", "rule": "california_hmo_pos_determination", "value": "45 business days", "day_type": "business", "clock_start": "receipt_of_dispute", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Cigna California Dispute Resolution Policy", "source_url": "https://www.cigna.com/health-care-providers/coverage-and-claims/appeals-disputes/california-provider", "quote": "Cigna Healthcare will send this determination letter within 45 business days of its receipt of a Cigna HealthCare of California, Inc. dispute." }, { "payer": "Cigna_CA", "rule": "ppo_epo_oap_notification", "value": "75 business days", "day_type": "business", "clock_start": "receipt_of_dispute", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Cigna California Dispute Resolution Policy", "source_url": "https://www.cigna.com/health-care-providers/coverage-and-claims/appeals-disputes/california-provider", "quote": "Health care providers will receive notification of PPO, EPO and Open Access Plus Products dispute resolutions within 75 business days of receipt of the original dispute. If approved, the Explanation of Payment will serve as notice of the determination." }, { "payer": "Health_Net_CA", "rule": "provider_dispute_filing", "value": "365 calendar days", "day_type": "calendar", "clock_start": "receipt_of_health_net_decision", "direction": "provider", "effective_date": "2025-02-06", "verification": "VERIFIED-PRIMARY", "source_title": "Health Net Provider Library \u2014 Dispute Submission (HMO, PPO, Medi-Cal)", "source_url": "https://providerlibrary.healthnetcalifornia.com/medi-cal/provider-manual/appeals-grievances-disputes/provider-appeals-dispute-resolution/dispute-submission-hmo-ppo-medi-cal.html", "quote": "Health Net accepts disputes, including appeals, from participating providers if they are submitted within 365 days of receipt of Health Net's decision" }, { "payer": "Health_Net_CA", "rule": "employer_sponsored_benefits_appeal_filing", "value": "365 calendar days", "day_type": "calendar", "clock_start": "notification_of_initial_decision", "direction": "provider", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Health Net Medicare Appeals & Grievances \u2014 \"Appeals Procedures for your Employer-Sponsored Benefits\"", "source_url": "https://www.healthnet.com/content/healthnet/en_us/members/employer/employer-medicare/member-appeals.html", "quote": "You must file your Appeal with Health Net within 365 calendar days after we notify you of the Initial Decision." }, { "payer": "Health_Net_CA", "rule": "ma_reconsideration_filing", "value": "60 calendar days", "day_type": "calendar", "clock_start": "receipt_of_written_organization_determination_notice", "direction": "provider", "effective_date": "2025-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.582(b) (+ healthnet.com member-appeals page, Medicare section)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.582", "quote": "A request for reconsideration must be filed within 60 calendar days after receipt of the written organization determination notice." }, { "payer": "Health_Net_CA", "rule": "employer_sponsored_external_review_decision", "value": "30 (days \u2014 the source does not state the day type)", "day_type": "unspecified", "clock_start": "iro_receipt_of_request_and_supporting_documents", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "Health Net Medicare Appeals & Grievances \u2014 \"Appeals Procedures for your Employer-Sponsored Benefits\"", "source_url": "https://www.healthnet.com/content/healthnet/en_us/members/employer/employer-medicare/member-appeals.html", "quote": "The independent review organization will provide its decision within 30 days after receiving the request for review and the supporting documents." }, { "payer": "Health_Net_CA", "rule": "ma_expedited_reconsideration_decision", "value": "72 hours", "day_type": "hours", "clock_start": "receipt_of_expedited_request", "direction": "payer", "effective_date": "", "verification": "VERIFIED-PRIMARY", "source_title": "42 CFR \u00a7 422.590(e)(1) (+ healthnet.com member-appeals page, Medicare section)", "source_url": "https://www.law.cornell.edu/cfr/text/42/422.590", "quote": "If we give you an expedited ('fast') decision, we must make our reconsideration decision as expeditiously as your health condition might require, but no later than 72 hours of receiving your request." }, { "payer": "Molina_Healthcare_CA", "rule": "provider_dispute_filing", "value": "365 calendar days", "day_type": "calendar", "clock_start": "last_date_of_action_on_issue", "direction": "provider", "effective_date": "2023-09-07", "verification": "VERIFIED-PRIMARY", "source_title": "Molina CA Medi-Cal Provider Dispute policy (also 2024 CA Marketplace Provider Manual, pp. 120-121)", "source_url": "https://www.molinahealthcare.com/providers/ca/medicaid/policies/provider-dispute.aspx", "quote": "Providers may dispute by submitting and completing a Provider Dispute Resolution Request Form within three hundred sixty-five (365) days from the last date of action on the issue." }, { "payer": "Molina_Healthcare_CA", "rule": "medicare_provider_dispute_filing", "value": "365 calendar days", "day_type": "calendar", "clock_start": "original_remittance_advice_date", "direction": "provider", "effective_date": "2023-01-01", "verification": "VERIFIED-PRIMARY", "source_title": "Molina CA Medicare Provider Manual (2023), pp. 105-106", "source_url": "https://www.molinahealthcare.com/~/media/Molina/PublicWebsite/PDF/Providers/common/medicare/provider-manual-ca.pdf", "quote": "Providers requesting a reconsideration of a claim previously adjudicated must request such action within 365 calendar days of Molina's original remittance advice date or longer as stated in the Provider Agreement." }, { "payer": "Molina_Healthcare_CA", "rule": "dispute_resolution_response", "value": "45 working days", "day_type": "working", "clock_start": "date_of_receipt_of_dispute", "direction": "payer", "effective_date": "2023-09-07", "verification": "VERIFIED-PRIMARY", "source_title": "Molina CA Medi-Cal Provider Dispute policy (also 2024 CA Marketplace Provider Manual, p. 121)", "source_url": "https://www.molinahealthcare.com/providers/ca/medicaid/policies/provider-dispute.aspx", "quote": "Molina will provide a written response to the provider within 45 working days from the date of the dispute and allows two levels of dispute." } ] }