California provider dispute resolution (PDR): how it works
California requires managed-care plans to run a formal provider dispute resolution process: a defined way for practices to contest claim denials, underpayments, and processing errors, with minimum filing windows and required acknowledgment and decision clocks.
Which plans does PDR cover?
Plans regulated by the California Department of Managed Health Care — HMOs and other Knox-Keene-licensed products — follow the PDR rules, while insurance policies regulated by the California Department of Insurance follow that department's parallel dispute rules. The same brand name can operate products under both regulators.
What does a PDR filing require?
A written dispute that identifies the provider and the claim and explains clearly why the practice believes the payer's determination is wrong, submitted through the plan's stated dispute channel inside the filing window. Plans must acknowledge receipt and issue a written determination within the required clocks.
Where are the actual deadlines?
Our verified tables quote each rule from the regulation or the payer's published provider documents: the DMHC table covers the Knox-Keene dispute rules, the CDI table covers insurance-code products, and each California payer page lists that payer's published windows.