Independent watchdog project. Not affiliated with the State of California, DHCS or Medi-Cal Dental.
Not the State of California
Your dentist says you need a crown. Somebody at your plan decides whether you get one. The rules for how that somebody decides, who they are allowed to be, how fast they must answer and what they owe you when the answer is no, all go by one dull name. Here it is, in plain words.
Start here
Utilization management, usually shortened to UM, is how a health plan checks whether the care a provider asks for is medically necessary and covered. It can happen at three moments: before the treatment (prior authorization), while it is under way, or after it has been done (prepayment or retrospective review).
UM also has a second, quieter job: watching the patterns. Are members getting far more of some treatment than makes sense? Or far less? The law requires the plan to look in both directions.
In Medi-Cal dental managed care, the requests that most often go through UM are the expensive ones. The member handbooks list the services that need approval first.
Root canals, Crowns, Full/partial dentures, Deep cleanings… General anesthesia and IV sedation.
What it is truly for
To understand why UM is wrapped in so many rules, start with how these plans are paid.
The dentist is paid for each procedure. The classic worry runs one way: too much treatment, because every procedure earns something. Review there is mostly about catching work that did not need doing.
The plan is paid a flat monthly amount per member, whether that member sees a dentist or not. Now the risk can run the other way: too little treatment, because every approved crown is a cost against money already received.
That is the whole puzzle of UM in a managed care plan. The same machinery that can stop unnecessary care can also be used to stop necessary care. The law does not pretend otherwise. It says, in so many words, that the plan must watch for both.
Mechanisms to detect both underutilization and overutilization of services.
And the state contract says what the program is for, in one sentence.
Contractor shall develop, implement, and continuously update and improve, a UM program that ensures appropriate processes are used to review and approve the provision of medically necessary dental covered services as identified in the Medi-Cal Dental Manual of Criteria.
Our read, clearly labeled
On paper, UM exists to make sure you get the care you need and not care you do not. In a plan paid by the head, it is also the exact spot where the plan's finances meet your treatment plan. That is not an accusation against anyone. It is why nearly every rule further down this page is a guardrail.
In practice
Simplified, but every step below is one the law writes a rule for.
Step 1. Your dentist asks
A treatment request goes to the plan
Usually with X-rays, charting and a note explaining why. You are rarely the one who sends it, which means you may not know it has been sent.
Step 2. The plan reviews
Checked against written criteria
The starting point is the state's Medi-Cal Dental Manual of Criteria. The plan may add its own clinical guidelines, but its definition of medically necessary may be no more restrictive than regular Medi-Cal's.
Step 3. A decision
Approve, modify, delay or deny
Anyone can approve. Only a qualified dentist may turn a request down or cut it back for reasons of medical necessity. Missing the deadline counts as a denial.
Step 4. You are told
A Notice of Action, in writing
On a state-approved form, explaining the reasons, the criteria used and how your condition does not meet them, plus how to appeal.
Step 5. You can push back
Appeal, then a State Hearing
A different, clinically qualified person must decide the appeal. If the plan still says no, the State can overrule it. The steps are below.
| Name | When | What it means for you |
|---|---|---|
| Prior authorization | Before treatment | The treatment waits until the plan says yes. This is the one members feel most, as a delay. |
| Concurrent review | During a course of treatment | An approved course of care can be looked at again partway through. |
| Prepayment or retrospective review | After treatment, before or after the dentist is paid | The care has happened. The question is whether the plan pays for it, which can shape what a dentist is willing to do next time. |
California's UM statute covers plans that review requests prospectively, retrospectively, or concurrently: Health and Safety Code 1367.01(a). DentaQuest's California provider manual names its criteria as the ones it uses for making medical necessity determinations for prior authorizations, post payment review and retrospective review, page 47.
The rulebook
A Medi-Cal dental plan is a Medicaid contractor under federal law, a licensed health plan under California law, and a party to a contract with the State. Each of those brings its own UM rules, and the plan has to satisfy every one of them together.
Layer 1. Federal regulation
42 CFR Part 438, Medicaid managed care
Sets the floor for every Medicaid plan in the country: who may deny, how fast, what the notice must say, the appeal, the State fair hearing, and the ban on paying reviewers to deny. Enforced through the State.
Layer 2. California statute and regulation
The Knox-Keene Act and title 22
Health and Safety Code 1367.01 is California's UM law for every licensed plan, dental plans expressly included, enforced by the Department of Managed Health Care. Title 22 of the regulations requires the dental director. Welfare and Institutions Code 14059.5 defines medically necessary for Medi-Cal.
Layer 3. The State contract and its letters
DHCS contract, Exhibit A7, and All Plan Letter 22-006
Turns the law into specific duties for these three plans, with the Medi-Cal Dental Manual of Criteria as the benchmark, mandatory notice templates, and audits by DHCS to check.
Layer 4. The plan's own paperwork
Provider manuals and member handbooks
How each plan says it does the job. Useful for seeing practice, but it sits underneath the other three. A handbook cannot give you fewer rights than the law does.
Where two layers set different numbers, the plan has to meet both, so the stricter one is the one that counts in practice. You will see this in the prior authorization deadlines below, where federal law, California law and the contract each set a deadline for the same decision.
The ins and outs
Twelve duties, each stated plainly with the rule underneath it. Most appear in more than one layer, which is a good sign of how seriously the law takes them.
The UM policies must be written, filed with the Department of Managed Health Care for approval, and disclosed to providers and members on request, and to the public on request.
HSC 1367.01(b); 42 CFR 438.210(b)(1); contract Exhibit A7, section 1.
Criteria must be developed with actively practicing providers, consistent with sound clinical principles, reviewed at least once a year, and applied consistently. The plan's idea of medically necessary may be no more restrictive than regular Medi-Cal's.
HSC 1363.5(b); 42 CFR 438.210(a)(5) and (b)(2)(i); contract Exhibit A7, section 2.2, and Exhibit A12.
A clerk, a manager or a computer may approve. A denial or a cut-back for medical necessity must come from a licensed professional competent to judge the clinical issue. The contract says a qualified dentist reviews all denials.
HSC 1367.01(e); 42 CFR 438.210(b)(3); contract Exhibit A7, section 2.1.
Dental decisions must be separated from fiscal and administrative management. Pay for anyone doing UM, person or company, may not be built to reward denying, limiting or stopping necessary care.
22 CCR 53913.5(a)(1); 42 CFR 438.210(e); contract Exhibit A7, sections 1.2 and 1.9.
Routine requests in days, urgent ones in 72 hours, and a missed deadline is treated as a denial you can appeal. Every deadline is set out below.
HSC 1367.01(h); 42 CFR 438.210(d); 438.404(c)(5); contract Exhibit A7, section 3.
A clear and concise explanation, the criteria used, and the clinical reasons. The contract goes further: the notice must explicitly state how your condition does not meet the criteria, on a standardized DHCS template the plan may not alter without DHCS approval.
HSC 1367.01(h)(4); 42 CFR 438.404(b); contract Exhibit A15, sections 6 and 7.1.
On request and free of charge, you are entitled to the documents behind the decision, including the medical necessity criteria. Before an appeal is decided, you are entitled to your case file.
42 CFR 438.404(b)(2); 438.406(b)(5); contract Exhibit A15, section 7.1 and section 11, item 15; HSC 1363.5(b)(4).
The plan must have ways to spot underuse as well as overuse, and report its utilization patterns to DHCS. California adds a duty to detect and correct under-service by providers who carry financial risk.
42 CFR 438.330(b)(3); contract Exhibit A7, section 4; 28 CCR 1300.70(b)(2)(H)(2).
A plan may hire another company to run UM. The hired company has to follow the same law, and the plan stays accountable for everything done in its name, which matters here because one plan's UM is run by another company.
HSC 1367.01(a); 42 CFR 438.230(b)(1); contract Exhibit A7, section 5, and Exhibit A5, section 6.1.
Federal rules now require Medicaid plans to post, every year, a list of what needs prior authorization, the share of requests approved, denied and approved after appeal, and how long decisions take. The first report was due 31 March 2026.
42 CFR 438.210(f), added by the federal prior authorization rule, CMS-0057-F.
Since 2025, California law says an algorithm or AI tool may not deny, delay or modify care for medical necessity, and may not replace the provider's judgment. A licensed professional must make that call.
HSC 1367.01(k), added by SB 1120. How far it reaches Medi-Cal is an open question.
The person who decides your appeal cannot be the one who made the first decision, or that person's subordinate. For a medical necessity denial, they must have clinical expertise in treating your condition.
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.
One more detail with a use. When a plan denies, delays or modifies a request, its written notice to your dentist must include the name and telephone number of the health care professional responsible, with a direct number or extension (HSC 1367.01(h)(4)). Your own notice is not covered by that rule. Neither the statute, the federal rule, the DHCS contract nor DHCS's instructions to the plans require the plan to put that name on the letter it sends you. So your dentist's office may be holding the name of the person who said no to you, and you can ask them for it.
The 2025 DHCS contract, Exhibit A15 section 7.1(e), and APL 22-006 both limit the name to written notification to the provider. Both also let a plan skip the direct number if it can show dentists have another easy way to reach the decision maker, such as a line to the UM unit.
Deadlines
A prior authorization request is your dentist asking your plan to approve treatment before doing it. The State sets how fast the plan must answer, how it must tell your dentist, and exactly what it must send you in writing. Everything below comes from the State's own instructions to the plans, with the stricter federal numbers shown where they differ.
“TO: ALL MEDI-CAL DENTAL MANAGED CARE (DMC) PLANS”
The address line of Dental All Plan Letter 22-006, issued by the California Department of Health Care Services on 20 July 2022. An All Plan Letter is the State's written instruction to the plans it contracts with. This one is addressed to the dental managed care plans alone, not to the public and not to medical plans. In Sacramento and Los Angeles counties that means every dental managed care plan there is: Health Net, Liberty Dental Plan, and California Dental Network (DentaQuest). The State's 2025 contract with those plans repeats the letter's deadlines almost word for word, in Exhibit A15, section 4.
5 business days
Counted from when the plan has the information it asked for, and never more than 14 calendar days after your dentist's request. Federal rules set a stricter outer limit for rating periods starting on or after 1 January 2026: 7 calendar days after the request.
APL 22-006, section II.A.1; contract Exhibit A15, section 4.2; HSC 1367.01(h)(1); 42 CFR 438.210(d)(1). The same contract's Exhibit A7, section 3, says 10 business days. Which number the State enforces is one of our open questions.
72 hours
When waiting the standard time could seriously jeopardize your life, your health, or your ability to attain, maintain or regain maximum function. Your dentist can say a request is urgent, or the plan can decide it is. The letter counts the 72 hours from when the plan has all the information it needs. Federal rules count 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).
30 days
When the plan reviews treatment after it happened, it must tell you its decision within 30 days of receiving the information it needs to decide.
APL 22-006, section II.A.3; contract Exhibit A15, section 4.4; HSC 1367.01(h)(1).
2 business days
After the decision, in writing, on the State's standard Notice of Action form, with the State's “Your Rights” pages attached. The plan must send both together every time, and it may not change the State's forms without the State's approval, except to fill in your details.
If the plan is cutting care you already have, the letter must be sent in time for you to ask to keep that care during an appeal. When the State audits the plan, it checks these deadlines against the postmark on the letter to you.
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).
24 hours
After the decision. By phone or fax first, then in writing, except when the plan is reviewing care already given.
The written notice to your dentist must include the name and phone number of the person who made the decision. That rule covers the letter to your dentist, not the letter to you, so your dentist's office may be holding that name.
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).
Up to 14 more days
Only if you ask for more time (or your dentist does, on a routine request), or the plan can show it needs more information and that the wait is in your interest. To take the extra time, the plan must either deny the request or ask your dentist right away for the specific information it still needs, and write to you and your dentist by the original deadline, or as soon as it knows it will be late, whichever is earlier. That letter must say:
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); 42 CFR 438.210(d).
It counts as a denial
On the day the deadline runs out. You can appeal it like any other no, and the plan must send you written notice of all your appeal rights.
APL 22-006, sections II.A.1 and II.A.2; 42 CFR 438.404(c)(5).
10 days’ notice
Before the plan reduces or suspends treatment it already approved, it must tell you at least 10 days ahead, so you have time to ask to keep that care while you appeal. Federal rules allow a few narrow exceptions.
APL 22-006, section II.A.4; contract Exhibit A15, section 4.5; 42 CFR 431.211.
When the decision rests in whole or in part on medical necessity, the notice must contain all of these:
For any other kind of no, such as a denial for missing information, the notice must still give a clear and concise explanation of the reasons. And you can ask, free of charge, for copies of every document and record the plan relied on, including any clinical criteria or guidelines.
APL 22-006, section II.C.1; contract Exhibit A15, section 7.1; HSC 1367.01(h)(4); 42 CFR 438.404(b).
The State's “Your Rights” pages must tell you:
The plan must also enclose the current State Hearing form. All three plans are licensed by California's Department of Managed Health Care, so each must also enclose that department's Independent Medical Review form, its instructions, the department's toll-free number, and an envelope addressed to it.
APL 22-006, section II.C.2; contract Exhibit A15, section 7.2.
| What has to happen | Deadline | Where it comes from |
|---|---|---|
| You appeal to the plan | Within 60 calendar days of the date on the Notice of Action. You can appeal by phone or in writing, and the date of a phone appeal counts as the filing date. | APL 22-006, sections IV.A and IV.B; 42 CFR 438.402(c)(2)(ii) |
| Plan confirms it got your appeal | In writing, within 5 calendar days, with the date it was received and the name, phone number and address of a contact | APL 22-006, section IV.C.1 |
| Plan decides your appeal | 30 calendar days, or 72 hours if expedited | APL 22-006, sections IV.C.2 and IV.D; 42 CFR 438.408(b) |
| You ask for a State Hearing | Within 120 calendar days of the plan's appeal decision. If the plan broke the notice or timing rules, you can go straight to a hearing, and the 120 days run from when the plan's notice was due, or from when you received a notice that broke the rules. | APL 22-006, section VI.A; California Department of Social Services |
| You keep existing care during the appeal | Appeal within 10 days of the notice, or before the change takes effect. This applies only when care already approved is being reduced, suspended or stopped, not to a new request that was refused. | APL 22-006, sections II.C.2 and IV.B; 42 CFR 438.420 |
The rule worth knowing
Silence is a no. If the plan does not decide in time, that counts as a denial, which means you can appeal it. And if the plan breaks the notice or timing rules, on the first decision or on your appeal, including sending you a notice that is not fully translated into your language, you are treated as having finished the plan's process and can go straight to a State Hearing.
Keep the envelope. When the State checks whether a plan met these deadlines, it goes by the postmark on the plan's letter to you. If a notice seems to have taken its time, the envelope shows when it was mailed.
Main source: DHCS Dental All Plan Letter 22-006, sections II, IV and VI, and the matching sections of the 2025 dental managed care contract, Exhibit A15. Deemed exhaustion: APL 22-006, section IV.C.3, and 42 CFR 438.408(c)(3). Federal law lets each State set the hearing window between 90 and 120 days, and California's is 120.
Who answers for it
Short answer: yes, UM runs straight through the dental director's job. The longer answer is more precise, and more useful.
On our dental directors page we set out the six duties California's regulation gives the dental director. Read the first one with UM in mind.
Ensuring that medical or dental decisions are rendered by qualified medical or dental personnel, unhindered by fiscal or administrative management.
That is UM in all but name. A dental decision, made by qualified people, with the money side kept out of it, is exactly what a prior authorization is supposed to be. Duties two to four, meeting standards of care, making sure protocols are followed, and setting dental policy, cover the criteria the reviewers use.
California's UM statute adds a second hook of its own. A plan that does UM must have a clinical lead, and for a dental plan that lead must hold a California license.
…shall employ or designate a medical director who holds an unrestricted license to practice medicine in this state … or, if the plan is a specialized health care service plan, a clinical director with California licensure in a clinical area appropriate to the type of care provided by the specialized health care service plan.
| Source | What it says | Is it a legal requirement |
|---|---|---|
| Title 22 regulation | Dental director ensures decisions are made by qualified people, unhindered by fiscal or administrative management, and develops dental policy | Yes |
| Knox-Keene Act | A plan doing UM must employ or designate a California-licensed clinical director | Yes |
| DHCS contract, Exhibit A2 | Dental decisions rendered by qualified dental personnel, and not unduly influenced by fiscal and administrative management | Yes, by contract |
| DHCS contract, Exhibit A5 | The dental director or a designee must head the plan's quality improvement committee, which is where utilization patterns are watched | Yes, by contract |
| DentaQuest and Liberty provider manuals | The dental director assesses over- and under-utilization of specialty referrals and reports to the UM committee. Dentists can ask a dental director for a peer-to-peer discussion. Liberty says its criteria are developed by its dental directors. | No, this is how the plans say they do it |
Contract exhibits from the 2025 DHCS dental managed care boilerplate, Exhibit A2 sections 5 and 6, and Exhibit A5 section 4. Manual language from DentaQuest's Provider Office Reference Manual, pages 41 and 78, and Liberty's California Provider Reference Guide, pages 45, 63 and 83 to 84. The UM committee passages in the two manuals are nearly word for word the same.
Put plainly
The dental director is not the person who stamps every form. The dental director is the person the law makes answerable for the system that does: that the reviewers are qualified, the criteria are sound, the money stays out, and the pattern of yeses and noes is being watched.
From the State's own audits
DHCS audits each dental plan and publishes the reports. UM is category one. Here is what those reports say, plan by plan, including where they found nothing wrong.
Audit reports 2020 to 2025
The most recent report, issued in February 2026 and covering April to December 2024, looked at prior authorization appeals. Nearly half were about braces, and every one of those was reviewed by a general dentist.
5 of 11 files reviewed were for orthodontic services. All five were reviewed by one of the two Plan Dental Directors, who are both general dentists and not qualified orthodontists.
Why that matters under the rules above. Federal law says an appeal of a medical necessity denial must be decided by someone with the appropriate clinical expertise in treating the condition (42 CFR 438.406(b)(2)), and the State's dental letter says a dental professional with clinical expertise in treating the member's condition. In DHCS's letter of 15 June 2026, the corrective action plan was still open, with DHCS asking for proof of an arrangement with one or more orthodontists. We have found nothing posted since.
2020 audit
Notices telling members a decision was delayed left out the date a decision could be expected, in 11 letters. DHCS found the plan did not effectively monitor and evaluate the functions of its ASO, the company it had hired to run the plan.
2021 audit
The administrator's policies did not match the Medi-Cal Dental Manual of Criteria for nine services. Its policy for children had frequency limits more restrictive than the program's, such as sealants once in a lifetime instead of every 36 months per provider, and the plan did not consider EPSDT when the normal criteria were not met. The report does not name the administrator. Health Net's own corrective action response for that audit describes Liberty Dental as Health Net's delegate. Closed December 2023.
2022 audit
None of 14 appeal resolution letters used the required DHCS template, and some carried the wrong procedure codes or tooth numbers. Closed August 2024.
2024 audit
No UM findings.
DHCS audit reports for 2021 and 2025. Other years from the DHCS dental managed care audit index. The two general dentists are not named in the report, and we are not guessing who they are.
Audit reports 2021 to 2024
One finding touching treatment requests in four audits, and it was about tracking and reporting. In the 2022 audit, requests the plan had put on hold for more information were not captured, reviewed, or validated, and the plan reported zero deferred adult, child, and EPSDT member TARs to the DHCS. The corrective action plan closed in December 2023.
The 2021 and 2023 audits had no UM findings. The 2024 report records no findings of noncompliance at all. That is worth saying as clearly as the findings are.
From the DHCS dental managed care audit index. We found no 2025 Liberty audit listed.
Left the program 30 June 2025
No longer one of your options, but it shows what repeated UM failure looks like on paper, year after year, in the program you are in.
| Audit | Files without the template | What else it found |
|---|---|---|
| 2022 | 16 of 16 | Nine of ten denials past the five business day limit. Two deferred requests took 36 and 83 business days. No mechanism to identify over- and under-utilization. The plan said it was unaware of the requirements. |
| 2024 | 16 of 16, marked repeat | Some decisions up to eight months late. To clear a backlog, the plan used an auto-approval system in which requests for the most used procedures were approved by the Dental Director without review of the documentation. |
| 2025 | 15 of 15, marked repeat | A request was denied because handwriting beside a tooth number confused the plan's software, which the plan confirmed reads requests without human verification. |
DHCS's closing letter of November 2025 required no further corrective action, because the contract had ended. The same letter records that the earlier corrective action plan on notice templates had been closed as satisfied on 14 February 2025.
DHCS audit reports for 2022, 2024 and 2025, and the DHCS letter of 25 November 2025. The 2020 audit had already recorded the plan denying these services administratively instead of reviewing for medical necessity.
For Health Net members, one more wrinkle. Since July 2025, DentaQuest reviews treatment requests for Health Net's plan, but grievances and appeals stay with Health Net. So the company that says no and the company that hears your appeal are different companies. That separation is not improper, and the law wants appeal reviewers who were not involved in the first decision. It does mean the paperwork can come from two places. The full picture is here.
DentaQuest's provider manual says of the plans it administers, which include Health Net's, that DentaQuest performs the review using one of two processes, prior authorization or prepayment review, page 23, and that it is not delegated for Health Net's grievances and appeals.
Using all of this
General information drawn from the public rules, not legal advice. We are a commentary site and cannot take on your case, but the people and numbers below can.
Step 1. Read the notice
It should be a Notice of Action on a DHCS form. It should give the reasons, the criteria used, and how your condition does not meet them. If it does not, that is itself worth raising.
Step 2. Ask for the criteria and your file
You have the right to copies of the documents behind the decision, including the medical necessity criteria, free of charge. Searching the three plans' member handbooks, we could not find that right stated, so you may need to ask for it by name.
Step 3. Talk to your dentist
Your dentist can ask the plan for a peer-to-peer discussion with one of its dental directors, and the plan's notice to your dentist must name the professional who made the decision.
Step 4. Appeal to the plan within 60 days
Call the member services number for your plan, listed on our dental managed care page. If waiting could seriously harm your health, ask for an expedited appeal, decided in 72 hours.
Step 5. Ask for a State Hearing within 120 days
If the plan upholds the denial, or does not decide your appeal within 30 days, the State can review it. If care you were already getting is being cut or stopped, ask within 10 days to keep it while you wait.
Step 6. Know about the Department of Managed Health Care
The DMHC Help Center takes complaints about licensed plans, and Medi-Cal members may be able to ask it for an Independent Medical Review. One trap: if your State Hearing has already taken place, you cannot then get an Independent Medical Review on the same issue. There is a dental caveat below.
Steps drawn from 42 CFR 438.404, 438.408 and 438.420; DHCS Dental APL 22-006; the DHCS Your Rights notice for Knox-Keene dental plans, which says that if the State Hearing has already taken place, the State Hearing has the final say; and 28 CCR 1300.74.30(f)(3).
Glossary
The terms that turn up in notices, handbooks and audit reports, in plain English.
The plan's system for reviewing whether requested care is medically necessary and covered, and for watching whether members as a whole are getting too much or too little care.
Permission from the plan before treatment. In Medi-Cal dental the request is often called a Treatment Authorization Request, or TAR, which is the term the State's audit reports use.
For adults in Medi-Cal, a service that is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. For anyone under 21 the standard is broader, see EPSDT. Source: Welfare and Institutions Code 14059.5.
Early and Periodic Screening, Diagnostic and Treatment, the federal children's benefit for under-21s. It covers care needed to correct or ameliorate a condition, and its dental services must at a minimum include relief of pain and infections, restoration of teeth, and maintenance of dental health. When a child does not meet the normal criteria, the plan still has to consider EPSDT. Source: 42 U.S.C. 1396d(r).
The State's rulebook for when each dental procedure is covered and how often. The contract makes it the benchmark for the plans' UM, and the plans may not be more restrictive.
The letter telling you the plan has denied, delayed, modified or stopped a service. Federal rules call the decision an adverse benefit determination. The letter must be on a DHCS template.
The letter telling you how the plan decided your appeal. The 120 days to ask for a State Hearing start from its date.
Deferred means the plan has paused a request to ask for more information. Modified means it approved something different or less than asked, such as fewer teeth or a cheaper procedure. Delayed means it has not decided in time. All of them come with notice rights, and a modification counts the same as a denial for appeal purposes.
A conversation between your dentist and a dentist at the plan about a decision. The plans' provider manuals offer it. It is the dentist's route, not yours, but you can ask your dentist to use it.
A company hired by the licensed plan to run parts of it, which can include UM. The plan stays legally responsible. More on who runs your plan.
If the plan fails to follow the notice and timing rules on your appeal, you are treated as having finished its appeal process and can go straight to a State Hearing.
An outside review of a plan's medical necessity decision, run by the Department of Managed Health Care. If it goes your way, the plan must follow it.
After an audit, the plan must submit a CAP saying how it will fix each finding. DHCS labels a finding repeat when the same deficiency turns up again in the next audit.
Being straight with you
Open questions, not accusations. If you can answer one, tell us.
Corrections welcome. If anything here is wrong, or you hold a document that settles one of these questions, send it to us and we will update the page and say what changed.
Show your work
Every rule on this page is quoted or paraphrased from one of these. Contract page references are to the 2025 boilerplate.
Check it against this page. If it is missing the reasons, the criteria, or arrived late, we want to see it, with your personal details blacked out.