What is prior authorization?
Prior authorization (PA) means the plan must approve certain care before it happens. A PA denial usually means the service has not been provided yet—that is different from a claim denial after care.
Overview for any state: Prior authorizations. This page is California-only.
Confirm plan type: California: Start Here.
California PA deadlines
Most California health care service plans and utilization review entities follow the Knox-Keene utilization review standards in the Health and Safety Code.
Medical services (non-drug)
After the plan has all information reasonably necessary to decide:
- Non-urgent: approve, modify, or deny within 5 business days (HSC § 1367.01(a)(1))
- Urgent (imminent and serious threat to health): within 72 hours (HSC § 1367.01(a)(2))
Denials must be communicated in writing to the patient within 2 business days in many cases. Plans must use qualified clinicians for medical necessity denials and publish PA criteria (HSC § 1367).
Prescription drugs
For most commercial plans under DMHC oversight (HSC § 1367.241):
- Non-urgent Rx PA: coverage determination or request for more information within 72 hours
- Exigent circumstances: within 24 hours
- If the plan misses these deadlines, the PA is generally deemed approved for the prescription duration (including refills)
CDI-regulated health insurance
Traditional insurers regulated by CDI also have PA timing rules under the Insurance Code (for example Ins. Code § 10123.135)—confirm on your denial notice and policy.
Electronic PA
California law pushes plans toward electronic prior authorization and transparency. Check the plan's provider portal or member site for the exact submission method.
Where to look up PA rules
Match tools to the exact plan on the ID card. Major 2026 Covered California carriers include:
- Kaiser Permanente: healthy.kaiserpermanente.org
- Anthem Blue Cross: anthem.com/ca
- Blue Shield of California: blueshieldca.com
- Health Net: healthnet.com
- Molina Healthcare: molinahealthcare.com
- LA Care, IEHP, Western Health Advantage, Sharp, Valley Health Plan — regional HMOs; use member grievance/appeals pages on each plan site
Medi-Cal managed care
Medi-Cal managed care plans (MCPs) follow federal Medicaid managed care appeal rules plus California Knox-Keene standards. PA and service denials often come as an adverse benefit determination. You generally have 60 days to appeal to the plan; the plan must resolve standard appeals within 30 days (or 72 hours if expedited) and send a Notice of Appeal Resolution (NAR).
After the plan process, you may request IMR through DMHC and/or a Medi-Cal fair hearing (hearing deadlines are shorter than IMR—file both timely if you want both). See Disability Rights California — Medi-Cal appeals.
If PA is denied
- Get the denial in writing with the specific clinical reason.
- Ask the treating clinician for records and a medical-necessity letter.
- File an appeal or grievance with the plan using the instructions on the notice.
- Track deadlines—see California internal appeals.
- If care cannot wait, request expedited review.
Building a strong appeal packet has a checklist.
Urgent and emergency care
California law includes strong protections for emergency services and post-stabilization care. Plans cannot use prior authorization to block emergency care that meets prudent layperson standards, and IMR is available when plans deny emergency payment (HSC § 1374.30).
For urgent non-emergency cases, use the 72-hour PA rule and expedited grievance/appeal paths in internal appeals and expedited appeals on the Appeals Roadmap.