CurrentmhnPolicy NOA

Appeals, Grievances, Independent Medical Review and State Hearings (Dental NOA)

Governs how members of Knox-Keene dental plans (NOA) may file appeals and grievances, request aid-paid-pending, seek Independent Medical Review (IMR) and request State Hearings; applies to members of the plan (California).

Policy Summary

Payermhn

PolicyAppeals, Grievances, Independent Medical Review and State Hearings (Dental NOA)

Policy CodePolicy NOA

Change TypeInformational — no material changes

Effective Date

Next Review Date

Key ActionIf you want Aid Paid Pending, file an appeal within 10 days of the Notice of Action or before the service change date and request Aid Paid Pending.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysstandard appeal window

10 daysAid Paid Pending request window

30 daysstandard appeal decision time

72 hoursexpedited appeal decision time

90 daysState Hearing expected decision time

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Appeals, IMR and State Hearing Criteria

Appeals/IMR/State Hearing procedural criteria

Procedural criteria and member entitlements for filing appeals, requesting Aid Paid Pending (APP), eligibility for Independent Medical Review (IMR), and requesting State Hearings.

ALL of the following

Member may file an internal appeal within 60 days from the date of the Notice of Action (standard timeframe).
Aid Paid Pending (APP) eligibility
- Member files the appeal within 10 days of the Notice of Action and requests Aid Paid Pending
- Member files the appeal before the effective date when the plan notifies of a service change and requests Aid Paid Pending

ALL of the following

Plan must decide standard (non‑expedited) appeals and provide a written decision within 30 days
If waiting 30 days could harm the member's health, member may request an expedited appeal and plan may decide within 72 hours; plan should attempt verbal notification for expedited decisions and mail a written notice for both expedited and standard appeals

ALL of the following

Member must request APP when filing the appeal (notify the plan that APP is requested) to continue receiving services while the appeal is pending
If member misses the 10‑day APP request window (or does not request before the service change effective date), member still has 60 days to file an appeal but will not receive APP pending the appeal decision

Independent Medical Review (IMR) eligibility

Member may request IMR from DMHC after they disagree with the plan's decision on their appeal, or if at least 30 days have passed since filing the appeal with the plan
Member may be eligible for IMR for disputes involving medical necessity, experimental or investigational treatments, or payment disputes for urgent (or urgent‑adjacent) services; DMHC staff will determine IMR eligibility

State Hearing entitlement and exceptions

Generally member must exhaust the plan's internal appeal process before requesting a State Hearing
Exceptions (Covered Services Exhaustion / direct‑right) allow requesting a State Hearing without exhausting internal appeal when the plan failed to timely or properly notify or otherwise violated certain rights (examples include failure to provide Notice of Action in preferred language, failure to issue the Notice of Action, or failure to decide an appeal within required timeframes)

ALL of the following

Member may request a State Hearing online (https://www.cdss.ca.gov/), by phone (1‑800‑743‑8525; TTY/TDD 1‑800‑952‑8349), or by mail/fax to the CDSS State Hearings Division; submission must include name, address, phone, SSN and/or CIN, and reason for the hearing; include representative info if filing on behalf of member
After requesting a State Hearing, decision may take up to 90 days; member may request an expedited hearing if waiting 90 days could harm health, and if granted a hearing decision may be issued within 3 days of CDSS receiving the case from the plan
CDSS will provide free interpreter services and reasonable accommodations for disabilities for the hearing

ALL of the following

Member does not have to pay for IMR or a State Hearing
A member may request IMR and a State Hearing concurrently or sequentially in some circumstances, but if a State Hearing is requested first and the hearing is held, the member cannot thereafter request IMR for the same matter (the State Hearing decision is final)

ALL of the following

DMHC provides IMR forms, applications, instructions, and toll‑free assistance (1‑888‑466‑2219; TDD 1‑877‑688‑9891) and online resources at https://www.dmhc.ca.gov/

ALL of the following

Member should first call their dental plan (1‑844‑233‑4522) and use the plan's internal complaint/appeal process before contacting DMHC, unless exceptions apply or expedited assistance is needed

Required Actions and Timelines for Providers and Members

Prior Authorization

Aid Paid Pending request timing

You may request Aid Paid Pending by filing an appeal within 10 days of the Notice of Action date, or before the effective date of the service change. If you file within those 10 days (or before the service change date), you should tell the dental plan when you file the appeal that you want Aid Paid Pending while the appeal is decided. If you miss the 10‑day window or do not file before the service change effective date, you still have 60 days from the Notice of Action date to file an appeal, but you will not receive Aid Paid Pending while the appeal is pending.

File appeal within 10 days of the Notice of Action date OR before the service change effective date to qualify for Aid Paid Pending.
If you request Aid Paid Pending, notify the plan when you file the appeal that you want Aid Paid Pending status.
If you file after the 10‑day window but within 60 days, you retain appeal rights but will not receive Aid Paid Pending.

Note

Appeal response timelines

Standard (non‑expedited) appeals: the dental plan must provide a written decision within 30 days of receiving your appeal. Expedited appeals: if waiting 30 days could seriously jeopardize the member's health or ability to attain/maintain maximum function, request an expedited appeal and explain why waiting would be harmful; the plan must attempt to notify you verbally and must issue its decision more quickly (typically within 72 hours). In both standard and expedited cases, the plan will mail a written Notice of Appeal Decision.

Standard appeal decision timeline: 30 days from appeal receipt.
Expedited appeal decision timeline: accelerated (generally within 72 hours) when delay could seriously jeopardize health; request ‘Expedited Appeal’ and explain risk of harm.
Plan must attempt verbal notice for expedited appeals and mail a written Notice of Appeal Decision for all appeals.

Note

IMR referral process

If you disagree with the plan’s decision after completing the internal appeal (or if other eligibility conditions apply), you may request an Independent Medical Review (IMR) through the state regulatory process. To seek IMR: exhaust the plan’s internal appeal process (or meet an exception identified by the regulator), then submit an IMR request to the Department that oversees managed care (DMHC). The DMHC staff will determine whether your case is eligible for IMR. IMR provides an independent, impartial review of medical necessity decisions, experimental/investigational treatment determinations, and urgent payment disputes for medically necessary or urgent services. IMR is free to you.

You generally must complete the plan’s internal appeal before requesting IMR; exceptions may apply.
If 30 days have passed since you filed your appeal with the plan, you may be eligible to request IMR.
To apply for IMR, contact the Department of Managed Health Care (DMHC) or use their website; DMHC provides forms, instructions, and phone assistance (1‑888‑466‑2219; TDD 1‑877‑688‑9891).
DMHC will screen for IMR eligibility and then conduct an independent review of the plan’s decision.
IMR is provided at no cost to the member.

Key Definitions

inv-06: Authorized Representative

DefinitionAn individual (friend, family member, advocate, dentist, or attorney) authorized to file an appeal on the member's behalf.

Plan-provided formThe dental plan may provide a form to identify and authorize the representative.

Representative actionsThe authorized representative may submit any materials the member wants the plan to consider for the appeal by phone, in writing, or electronically.

inv-07: Independent Medical Review (IMR)

DefinitionA DMHC process providing impartial review of plan medical decisions by independent dentists not connected to the plan.

When to requestMembers may request IMR if they disagree with the plan's decision on services, or if at least 30 days have passed since filing an internal appeal and they remain dissatisfied.

DMHC roleDMHC staff will determine whether the issue meets IMR criteria and, if eligible, conduct the independent review.

inv-08: Aid Paid Pending (APP)

DefinitionAid Paid Pending (APP) is continuation of services while an appeal is pending when the member timely requests APP.

Timeframe to requestTo qualify for APP, the member must file an appeal within 10 days of the Notice of Action or before the date the plan notifies of a service change.

If lateIf the 10-day timeframe is missed (but appeal is filed within the standard 60 days), the member may still appeal but will not receive APP while the appeal is decided.