Medi-Cal managed-care appeal rules combine the federal Medicaid managed-care regulation (42 CFR Part 438) with DHCS All Plan Letter 21-011. The values below are the operative California implementation, quoted from the federal text and corroborated by the APL where noted.
Day types are not interchangeable: calendar, business, and month windows each count differently, and month windows are never converted to days. Every value below is quoted from its primary source.
Deadlines you must hit
MCO appeal filing
60 calendar daysClock starts: date on adverse benefit determination notice
an enrollee has 60 calendar days from the date on the adverse benefit determination notice in which to file a request for an appeal
Source: 42 CFR § 438.402(c)(2)(ii)
Continuation of benefits request
10 calendar daysClock starts: later of plan sending abd notice or intended effective date of action
'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.
State fair hearing filing
120 calendar daysClock starts: date of notice of appeal resolution
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 response clocks
MCO standard resolution
30 calendar daysClock starts: receipt of appeal
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.
MCO expedited resolution
72 hoursClock starts: receipt of expedited appeal
the State must establish a timeframe that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal.
Source: 42 CFR § 438.408(b)(3)
MCO extension
14 calendar daysClock starts: original deadline
The MCO, PIHP, or PAHP may extend the timeframes from paragraph (b) of this section by up to 14 calendar days if—
Source: 42 CFR § 438.408(c)(1)
Deemed exhaustion MCO timing failure
Procedural ruleIn the case of an MCO, PIHP, or PAHP that fails to adhere to the notice and timing requirements in § 438.408, the enrollee is deemed to have exhausted the MCO's, PIHP's, or PAHP's appeals process.
Source: 42 CFR § 438.402(c)(1)(i)(A)
Standard authorization decision
7 calendar daysClock starts: receipt of service request
may not exceed 7 calendar days after receiving the request
Source: 42 CFR § 438.210(d)(1)(i) (as amended by CMS-0057-F, 89 FR 8980)
Expedited authorization decision
72 hoursClock starts: receipt of service request
no later than 72 hours after receipt of the request for service
Source: 42 CFR § 438.210(d)(2)(i)
Advance notice termination reduction
10 calendar daysClock starts: counts backward from intended date of action
The State or local agency must send a notice at least 10 days before the date of action, except as permitted under §§ 431.213 and 431.214.
Source: 42 CFR § 431.211 (via § 438.404(c)(1) cross-reference)
Reference information for provider billing teams, not legal advice. Windows depend on the plan's regulator and product, so confirm against your contracted provider manual. Sources retrieved 2026-07-04.