Notification Delays

Provider Type

  • Participating Physician Groups (PPG)
  • Hospitals

When an enrollee has made a request for a service, the PPG must notify the enrollee of its determination within five business days from receipt of the information reasonably necessary to render a decision, in accordance with Health & Safety Code Section 1367.01, but no later than 14 calendar days after the date the PPG receives the request for a standard prior authorization determination. The PPG may offer an additional 14 calendar days when the enrollee or the enrollee's provider requests an extension or if the PPG justifies a need for additional information and how the delay is in the enrollee's best interest (for example, the receipt of additional medical evidence from non-participating providers may change a PPG's decision to deny). Any decision delayed beyond these time limits is considered a denial and must be immediately processed accordingly.