California prior authorization laws (2026)
General reference compiled from public statutes and the AMA state-law chart. This is not legal advice. Statutes change; confirm the current law before relying on it.
Decision deadlines
Prior authorization (DMHC-regulated health care service plans (Knox-Keene))
Standard decision: 5 business_days. Expedited: 72 hours.
CA Health & Safety Code § 1367.01(h) · sourcePatient-protection mandates
Independent Medical Review
A denial, modification, or delay based on medical necessity is eligible for an external Independent Medical Review (IMR) administered by the DMHC. The IMR decision is BINDING on the plan; if favorable the plan must authorize within 5 business days. Historically the plan denial is reversed/overturned in roughly 73% of IMR cases.
CA Health & Safety Code §§ 1374.30-1374.35 · sourceFrequently asked questions
How long does an insurer have to decide a prior authorization in California?
Under CA Health & Safety Code § 1367.01(h), a standard prior authorization decision is generally due within 5 business_days, and an expedited decision within 72 hours. Confirm the current statute, as timeframes vary by plan type.
What prior authorization patient protections does California have?
California law includes independent medical review. Each is grounded in a specific statute (see above).
Other states
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