Appeals, Continuation of Benefits, Independent Medical Review (IMR) and State Hearing Procedures — Managed Dental Plans (Knox‑Keene)
Governs member rights and procedures to appeal benefit decisions, request continuation of benefits during appeal, request independent medical review (IMR) and state-level hearings for managed dental plan enrollees in California (Knox‑Keene plans). Affects members of the dental plan and their authorized representatives.
No material clinical or coverage changes in this revision.
Appeals, IMR and State Hearing Criteria & Timelines
Appeal and external review procedural criteria
Procedural criteria and timelines for filing and deciding appeals, expedited appeals, continuation of benefits during appeal, Independent Medical Review (IMR) eligibility, and state hearing requests (California).
Time to file appeal
- Member requests an appeal within 60 days from the date on the Notice of Action (NOA).60 days
If the 60-day limit is missed, member may still file but may not qualify for continuation of benefits.
- If services are reduced, suspended, or terminated and member requests continuation of benefits (stay) they must request the appeal within 10 days of the NOA or before the date services change to qualify for continuation of benefits during the appeal.
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