(And How Banjo Health Helps You Stay Compliant and Competitive)
As payers and PBMs navigate evolving regulatory requirements, California’s prior authorization (PA) laws—governed under 28 CCR § 1300.67.24 and HSC § 1367.01—represent both a challenge and an opportunity.
At Banjo Health, we understand how critical it is for you to manage compliance efficiently while optimizing workflows and outcomes. Let’s break down what these regulations mean—and how Banjo’s AI-powered PA software ensures you're ready.
California’s Mandated Response Times for Prior Authorization
Timely decision-making is no longer optional in California:
● Medical Service PAs: Must be processed within 5 business days of receipt
● Urgent Requests: Must be completed within 72 hours
● Prescription Drug Requests: Must be completed within 24–72 hours, depending on urgency
Banjo Health automates PA decisioning workflows, helping payers meet these strict timelines with built-in rules engines, smart routing, and urgency detection.
California Standardized Prior Authorization Forms & ePA Support
California requires a standard PA form (Form 61-211) and supports electronic prior authorization (ePA) using the NCPDP SCRIPT standard.
With Banjo’s seamless ePA integration, you can instantly meet state-mandated formatting requirements, reduce friction, and improve processing accuracy—all while delivering a better provider experience.
California Prior Authorization Transparency & Recordkeeping Requirements
● Health plans must retain PA documentation for 10 years
● Denial notices must clearly explain the reason, especially for prescription drugs
Banjo’s platform provides audit-ready logs and auto-generated denial rationales, ensuring transparency and regulatory alignment without the administrative burden.
California Prior Authorization Clinical Criteria& Denial Integrity
California restricts payers from requesting more than what is reasonably necessary to determine medical necessity. Additionally, prior authorizations cannot be rescinded or modified after care is delivered in good faith.
Our platform aligns your criteria with evidence-based guidelines and embeds them directly into the decision-making process—minimizing risk of improper denials and protecting plan reputation.
California Prior Authorization Reviewer Qualifications
All PA determinations must be reviewed by a qualified physician or healthcare professional who is competent in the clinical area in question.
Banjo’s intelligent routing engine ensures peer reviews and escalations are always handled by the appropriate licensed professionals, reducing compliance errors and delays.
Why This Matters for Payers & PBMs
Failing to comply with California’s PA mandates can lead to:
● Regulatory fines
● Plan disqualification
● Member dissatisfaction
● Increased provider abrasion
Banjo Health is built to protect your organization from all of the above—while reducing turnaround times and administrative overhead.
Ready to Streamline PA Compliance in California?
With Banjo Health, you’re not just meeting California’s requirements—you’re setting a new standard for prior authorization automation.
