MedicaidAdministrativeHigh impact
26-642 Submit Medi‑Cal Rx and Fee‑for‑Service Carved‑Out Medication Claims Correctly
Health Net·CA·Pharmacy
Effective date
Jul 27, 2026
We identified it
Jun 20, 2026
Summary
Effective July 27, 2026, Health Net will begin denying claims for carved-out medications that should be billed to Medi-Cal Rx (pharmacy claims) or Medi-Cal Fee-for-Service (medical/institutional claims) instead of Health Net. Providers must identify carved-out medications and submit claims to the correct Medi-Cal payer to avoid denials and resubmission delays.
Action Required
Before July 27, 2026: Billing team must review the Medi-Cal Rx Pharmacy Carve-Out Scope Document to identify carved-out medications and update billing workflows. Bill pharmacy carved-out medications to Medi-Cal Rx and medical/institutional carved-out medications to Medi-Cal Fee-for-Service instead of Health Net. Update billing system rules and staff training. Claims submitted incorrectly to Health Net will be denied and require resubmission to the appropriate Medi-Cal payer.