Independent watchdog project. Not affiliated with the State of California, DHCS or Medi-Cal Dental.
Not the State of California
If you are in Sacramento or Los Angeles County and you take Health Net, Liberty Dental Plan or California Dental Network (DentaQuest), the plan is working from a contract and a stack of letters that most dentists never see. This page is what is in them. Not the plan's summary of them. The rules themselves, with the citation under each one, so you can quote it back.
The two documents to keep open
Both links leave this site and land on the State's own pages. We are not the State, we are not your plan, and nothing here is legal advice.
Why we built this
A member who calls a plan to say a denial was wrong is one call in a queue. A treating dentist who writes that the denial cites criteria the plan will not produce, from a reviewer the plan will not name, past a deadline the contract sets, is a compliance problem with a paper trail. Same facts. Different weight. That is not fair, but it is true, and it is worth using.
Most of what follows is not new law. It is in the contract your patients' plan signed with the State, in Health and Safety Code section 1367.01, and in the All Plan Letters DHCS sends the plans. The plans know it. The question this page is built around is whether the dentist across the table knows it too.
We are a commentary project, not a billing service and not a lawyer. We have no interest in your rates. Everything here is about the clock, the criteria and the decision, because those are the things that decide whether your patient gets the treatment you asked for.
What this page is not. It is not a claims or payment guide, it is not a template for a dispute, and it does not tell you your patient's case is winnable. It is a list of duties the plan already carries, with the source beside each, so that when you write to the plan you can be specific instead of aggrieved.
Our read, clearly labeled
The most useful thing on this page is probably the name and number rule. When a plan denies, delays or modifies a request, the written notice to the provider has to carry the name and a direct telephone number for the professional who made that call. The letter to your patient does not. So in a great many denials, the only person in California holding the name of the reviewer is the dentist. Your patient cannot ask for what they do not know exists.
Start with the calendar
These are the plan's deadlines, not yours. They are set by the State's instructions to the plans and repeated almost word for word in the 2025 contract. A member rarely knows they exist. Your office can time them from the day you transmit.
Counted from when the plan has the information it asked for, and never more than 14 calendar days from your request. Federal law sets a stricter outer limit of 7 calendar days for rating periods starting on or after 1 January 2026.
APL 22-006, section II.A.1; contract Exhibit A15, section 4.2; HSC 1367.01(h)(1); 42 CFR 438.210(d)(1).
Where the standard timeframe could seriously jeopardize life, health, or the ability to attain, maintain or regain maximum function. You can say a request is urgent. The plan can also decide it is. The letter counts 72 hours from when the plan has what it needs; the federal rule counts from when the request arrives.
APL 22-006, section II.A.2; contract Exhibit A15, section 4.3; HSC 1367.01(h)(2); 42 CFR 438.210(d)(2).
After the decision, by telephone or fax, then in writing. That written notice to you is the one that must carry the reviewer's name and number. The exception is review of care already provided.
APL 22-006, sections II.A.1 and II.C.1(e); contract Exhibit A15, section 4.2; HSC 1367.01(h)(3) and (4).
In writing, on the State's standard Notice of Action template with the Your Rights pages attached. The plan may not alter those forms without DHCS approval. If your patient never got one, that is a second failure on top of the first.
APL 22-006, sections II.A, II.A.1 and II.B; contract Exhibit A15, sections 4.1 and 4.2; HSC 1367.01(h)(3).
Only if you or the member ask for it, or the plan can show it needs more information and that the wait is in the member's interest. To take it, the plan must write to you and the member by the original deadline saying exactly what it asked for and did not get, when to expect a decision, and that the member may file a grievance about the delay.
APL 22-006, sections II.A.1 and II.A.2; contract Exhibit A15, sections 4.2 and 4.3; HSC 1367.01(h)(5).
On the day the deadline runs out, an undecided request counts as an adverse benefit determination. Your patient can appeal it like any other no, without a letter in hand, and the plan owes written notice of appeal rights.
42 CFR 438.404(c)(5); APL 22-006, sections II.A.1 and II.A.2.
One number on this page is disputed, and we will not pretend otherwise. The same 2025 contract says 5 business days in Exhibit A15 section 4.2 and 10 business days in Exhibit A7 section 3. Which one DHCS enforces is an open question we have not resolved. The shorter number is the one the All Plan Letter uses, so it is the one we cite, but if a plan quotes you ten, that is where it is getting it. Our full breakdown of the deadlines is here.
The single most useful sentence
When a plan denies, delays or modifies a requested service, California law requires the written notice it sends the provider to identify the professional responsible for the decision, with a direct telephone number or extension.
“… the name and telephone number of the health care professional responsible for the denial, delay, or modification.”
California Health and Safety Code section 1367.01(h)(4). The 2025 contract at Exhibit A15 section 7.1(e) and APL 22-006 both carry the same duty and both limit it to the written notification to the provider. Both also allow the plan to leave out a direct number if it can show that providers have another easy way to reach the decision maker, such as a line into the utilization management unit. Neither the statute, the federal rule, the contract nor the APL requires that name on the letter your patient receives.
Two practical consequences follow.
If the name is missing from your notice, the notice is incomplete. That is a defect in the plan's process, separate from whether the clinical call was right, and it is worth saying so in writing.
If the name is there, your patient probably wants it. They have the right to appeal, and they are entitled to the criteria and the case file. Knowing that a named licensed dentist signed off, and that the plan must produce the criteria that dentist used, changes the character of an appeal. Many members never learn any of this because the only document carrying it went to your office.
Which name, though. The reviewer who signs a denial is not necessarily the plan's dental director. The dental director is the one named officer responsible for seeing that clinical decisions stay clinical. We keep a page on who currently holds that post at each of the three plans, and how hard it was to find out. See who your plan's dental director is.
Who is on the other end
A clerk can approve. A system can approve. Approval is not the regulated act. A denial or a cut-back on grounds of medical necessity is.
“No individual, other than a licensed physician or a licensed health care professional who is competent to evaluate the specific clinical issues involved in the health care services requested by the provider, may deny or modify requests for authorization of health care services for an enrollee for reasons of medical necessity.”
California Health and Safety Code section 1367.01(e). The 2025 contract, at Exhibit A7 section 2.1, says a qualified dentist reviews all denials. The federal rule at 42 CFR 438.210(b)(3) says the same thing in Medicaid terms.
Three more duties sit alongside it, and each is worth knowing because each gives you something specific to ask about.
Dental decisions must be rendered by qualified dental personnel and kept unhindered by fiscal or administrative management. Pay for anyone doing utilization review, person or company, may not be structured to reward denying, limiting or discontinuing necessary care.
22 CCR 53913.5(a)(1); 42 CFR 438.210(e); contract Exhibit A7, sections 1.2 and 1.9.
Since 2025, California law says an algorithm or artificial intelligence tool may not deny, delay or modify care on medical necessity grounds, and may not substitute for provider judgment. A licensed professional has to make that call. How far it reaches Medi-Cal managed care is not settled.
HSC 1367.01(k), added by Senate Bill 1120.
Every dental plan must appoint a dentist as dental director. The regulation makes that one person responsible for keeping dental decisions with qualified dental personnel, for the standard of care, for dental policy, and for quality of care grievances.
22 CCR 53913.5. The six listed duties are a floor, not a ceiling. The full list, with what it means.
Ask for it in writing
A plan that denies on medical necessity is relying on written criteria. Those criteria are not a trade secret you have to accept on faith.
HSC 1367.01(b) and 1363.5(b); 42 CFR 438.210(a)(5), (b)(1) and (b)(2)(i); 42 CFR 438.404(b)(2) and 438.406(b)(5); contract Exhibit A7, sections 1 and 2.2, Exhibit A12, and Exhibit A15, sections 6, 7.1 and 11 item 15.
Our read, clearly labeled
The entitlement to the criteria and the case file runs to the member, not to you. In practice you are usually the one who will read them and know what they mean. A short authorization from your patient, on file, turns a right they cannot use into one you can exercise on their behalf. That is worth setting up once rather than case by case.
After a no
An appeal in Medi-Cal managed care is not a rerun in front of the same person. The rules are specific about who may decide it.
42 CFR 438.406(b)(2) and (b)(5); 438.402(c); 438.408; APL 22-006, sections I.A, III.A, III.B and III.C.
Know which company you are appealing to. Two of the three plans are run day to day by the same administrator, and for one of them that company's name is nowhere on the member's card. Its own provider manual states that it is not delegated to handle grievances and appeals for that plan's members, which go to the plan itself at a different address. Sending an appeal to the administrator when it belongs with the plan wastes a deadline. Which company handles what.
The other failure mode
Not every problem is a denial. Sometimes the treatment is approved and there is nowhere to send them, or they cannot get in your door inside the time the plan promised. That has its own rules and its own exit.
| Appointment | Standard |
|---|---|
| Emergency | 24 hours. Pain, swelling or bleeding. DHCS tells members to telephone rather than send anything in writing. |
| Urgent | 72 hours. |
| Routine | 4 weeks. |
| Specialist | Counted from when the referral was authorized, not from when the member asked. 30 calendar days for children and 30 business days for adults on the current form. |
Sacramento County runs Geographic Managed Care, so enrollment is mandatory and a member cannot simply leave. The Beneficiary Dental Exception is the statutory route back to fee-for-service for a member who cannot be seen inside those standards. Three things about it are worth knowing at the chair.
A member who has been bounced for months usually does not know this exists. Telling them takes thirty seconds. The whole process, and what twelve months of the State's own reports show about how often it works.
Los Angeles runs a voluntary Prepaid Health Plan. Members are in a plan because they opted in, and roughly nine in ten Medi-Cal dental members in the county never did. A member who wants out changes or drops their dental plan through Medi-Cal Health Care Options on 1-800-430-4263, and there is no exception process to run because there is nothing holding them in.
Timely access standards as DHCS states them in the monthly BDE reports under “Timely access requirements for appointment timeframes per the DMC contract,” and on the BDE request form. County enrollment rules per the two county arrangements.
Your directory entry is part of this. California law requires the plan to update its online provider directory at least weekly once it is told something that affects accuracy, and that duty is only as good as what you send it. If your office is closed to new Medi-Cal patients, has moved, or no longer has the specialist a member is being referred to, the plan needs to hear it from you. Directory accuracy is the thing this project spends most of its time on, and the gap is rarely one-sided.
Worth preparing for
All Plan Letter 26-006, issued 24 June 2026, tells the dental plans to open a set of standard data connections. Most coverage of it is about members. Three parts are about you.
A Provider Access API. An in-network dentist can ask the plan for the data it holds on a patient it has attributed to them, back to dates of service from 1 January 2016, and the plan must answer within one business day. Claims, encounters, the clinical data set, and prior authorizations with the documentation attached.
A Prior Authorization API, loaded with the plan's own list of covered items and services that need approval, and identifying all documentation the plan requires for each of them. It must answer with an approval and its end date, a denial with a specific reason, or a request for more information.
Each plan must publish, on its website and through its usual provider channels, plain language information on how a provider requests member data, including how its attribution process works. Attribution is what decides whether the plan counts a patient as yours at all.
APL 26-006, section F, Provider Resources; 42 CFR 431.61(a)(5).
Our read, clearly labeled
The second card is the one to watch. A published, machine-readable list of every document the plan requires for every procedure that needs approval is the end of a familiar argument, the one where a request is deferred for something nobody told you to send. If your plan publishes that list and it does not match what its reviewers ask for in practice, that gap is now documented on the plan's own website. Our full write-up of the letter, with a short track to listen to, is here.
Your patient can watch too. From 1 January 2027 the plan must show a prior authorization in a health app the member chooses, within one business day, including the specific reason for a denial and the clinical documentation you submitted. It may be the first time a member can see that you asked, what you sent, and what came back. What the member sees.
The point of the whole page
Every plan produces a provider manual, and every provider manual is the plan's account of its own obligations. It is not wrong, usually. It is selective, and it is always downstream of the documents below. These are the primary ones, in the order we would check them.
DHCS's written instructions to the dental plans, published as they are issued. This is where a rule changes first. The plans get it, then update their manuals, then tell you. Reading the letter means you know months earlier, and you know what the plan was actually told rather than how it summarized it.
The State's indexThe agreement each plan signs with DHCS. Exhibit A7 is utilization management, Exhibit A15 is authorization timeframes, notices and appeals, Exhibit A5 covers delegation to another company, and Exhibit A12 covers the criteria. Almost every number on this page traces to it. When a plan tells you its policy, this is the document that says whether its policy is allowed.
Open the contract (PDF)The State's rulebook for when a procedure is covered and how often. The contract makes it the benchmark for the plans' utilization management, and a plan's definition of medically necessary may be no more restrictive than it. A plan may add clinical guidelines on top. It may not quietly raise the bar.
Medi-Cal Dental for providersSince 2026, each plan must post on its own website, by 31 March, the previous year's figures: the list of items and services requiring prior authorization, the share approved, denied and approved after appeal, the share where it took an extension, the expedited figures, and the average and median time to decide. The first set fell due 31 March 2026.
The nine numbers, and where they come fromPlans run advisory committees that meet on a schedule and, where the plan publishes them, produce minutes. APL 26-006 now requires the plans to put their member education materials in front of those committees. It is one of the few places you can read what a plan is telling its own advisors rather than what it tells its network.
What the committees now have to reviewDHCS audits each plan and publishes the report with the plan's corrective action plan. The Department of Managed Health Care publishes every enforcement action it has taken, with the settlement documents. If a plan has been fined for exactly the thing it is doing to your patient, that is a fact you can cite.
Our ledger of the fines, with the documentsWrite it down as it happens. Date of transmission, what you asked for, what came back, the date on the notice, the postmark, the name on the notice, every call with the date, time, name and reference number. Nearly every route below asks for that record, and nearly nobody has it at the point they need it.
Ask in writing, even when you phone. A plan may answer a phone call informally and a letter formally. When you want the criteria, the reviewer, or a reason for a deferral, a short written request creates a document, starts a clock, and can be attached to whatever comes next.
When it still does not move
These are separate channels with separate purposes, and using the wrong one costs weeks. Two regulators sit over these plans: DHCS holds the Medi-Cal contract, the Department of Managed Health Care holds the Knox-Keene licence.
First, the plan
Peer-to-peer review with a plan dentist, where the plan's provider manual offers it, then the plan's grievance and appeal process. A provider may file an appeal with the member's written consent. Check where grievances and appeals actually land for your plan before you send anything, because two of the three plans are run day to day by the same administrator, and that administrator is not always delegated to handle them.
For the patient, in parallel
The member's own appeal, then a State Hearing, and for a medical necessity denial an Independent Medical Review through the Department of Managed Health Care. These belong to the member, not to you, but a member with a treating dentist's written statement is in a very different position from one without. The member's routes, step by step.
For your own dispute with the plan
The Department of Managed Health Care takes a Provider Complaint Against a Plan. It requires you to have gone through the plan's own provider dispute resolution process first, for at least 45 working days or until you have its written determination, whichever is shorter, and from 1 July 2026 the claim's last date of service must be within 30 months. The Provider Complaint Branch is on 1-877-525-1295.
For a pattern, not a case
DHCS audits the plans and can require a corrective action plan or impose sanctions. APL 26-006 ends with the standard line that failure to meet its requirements may result in a corrective action plan or monetary sanctions. A single late notice is a case. Twenty of them, documented, is a pattern, and patterns are what audits are for.
General Medi-Cal Dental questions go to the Medi-Cal Dental Telephone Service Center for providers, on 1-800-423-0507, weekdays 8:00 a.m. to 5:00 p.m. That line is the Medi-Cal Dental program, not your managed care plan, so it is the wrong desk for a dispute with the plan and the right one for questions about the program underneath it.
Being honest about it
If you practice in either county and take one of these plans, we would like to hear what actually happens: what your notices carry, whether the deadlines hold, and whether anyone answers the number on the letter. Redact your patient before you send anything. Tell us what you are seeing.
Read it yourself
Nothing on this page is our opinion of what the rules should be, except where a box says so in the heading.
A missing reviewer name, a deadline that came and went, criteria the plan will not produce. Send it with your patient's details blacked out. We publish patterns, never people.