California DMHC-regulated commercial plans: provider dispute deadlines (2026, verified)
Health plans regulated by the California Department of Managed Health Care (DMHC) — HMOs and other Knox-Keene-licensed products — may not impose a provider-dispute filing deadline shorter than the 365-day floor in 28 CCR § 1300.71.38(d)(1). That floor applies to DMHC-regulated business regardless of what the payer's national policy says. Which regulator governs a claim depends on the product, not the payer name.
Per Appealant’s verified payer-deadline database, every value on this page is quoted verbatim from a primary source — the governing federal or California regulation — with the source linked and its effective date shown (sources re-retrieved 2026-07-04).
Calendar, business, and working days are not interchangeable, and month-based windows are never converted to day counts. Source documents were re-retrieved and verified 2026-07-04.
How long is the provider dispute filing window for California commercial plans regulated by the DMHC (Knox-Keene HMO)?
365 calendar days, counted from date of plan action or inaction deadline. Verified verbatim by Appealant from the primary source — 28 CCR § 1300.71.38(d)(1), effective 2004-01-01 — most recently re-retrieved 2026-07-04.
What is the medical necessity UM appeal to plan deadline for California commercial plans regulated by the DMHC (Knox-Keene HMO)?
60 working days, counted from capitated provider date of determination. Verified verbatim by Appealant from the primary source — 28 CCR § 1300.71(e)(5) (DMHC AB1455 Full Regulation text), effective 2004-01-01 — most recently re-retrieved 2026-07-04.
Full rules table, with verbatim sources
| Rule | Value | Clock starts | Applies to | Verbatim source text |
|---|---|---|---|---|
| Provider dispute filing window | 365 calendar days | date of plan action or inaction deadline | Provider deadline | 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. 28 CCR § 1300.71.38(d)(1) (effective 2004-01-01) |
| Provider dispute acknowledge electronic | 2 working days | date of receipt of dispute | Payer / reviewer clock | (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 28 CCR § 1300.71.38(e)(1) (effective 2004-01-01) |
| Provider dispute acknowledge paper | 15 working days | date of receipt of dispute | Payer / reviewer clock | (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. 28 CCR § 1300.71.38(e)(2) (effective 2004-01-01) |
| Provider dispute resolution written determination | 45 working days | date of receipt of dispute | Payer / reviewer clock | (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 … 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. 28 CCR § 1300.71.38(f) (effective 2004-01-01) |
| Prompt pay all plans | 30 calendar days | date of receipt of claim | Payer / reviewer clock | 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 Cal. Health & Safety Code § 1371(a)(1) (operative Jan. 1, 2026) (effective 2026-01-01) |
| Prompt pay interest rate | 15 percent per annum (interest rate) | first calendar day after 30 calendar day period | Payer / reviewer clock | interest shall accrue at a rate of 15 percent per annum beginning with the first calendar day after the 30-calendar-day period Cal. Health & Safety Code § 1371(a)(4) (operative Jan. 1, 2026) (effective 2026-01-01) |
| Medical necessity UM appeal to plan | 60 working days | capitated provider date of determination | Provider deadline | 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. 28 CCR § 1300.71(e)(5) (DMHC AB1455 Full Regulation text) (effective 2004-01-01) |