MedicaidPrior AuthMedium impact
26-628 Updates to Prior Authorization Requirements
Health Net·CA · Oncology, Neurology, Urology +1 more·Prior Authorization
Effective date
Apr 1, 2026
We identified it
Jun 20, 2026
Summary
CalViva Health updated prior authorization requirements effective immediately for incontinence supplies (PA only required beyond 186 units/month or $165 benefit limit) and added PA requirements for multiple new services including genetic testing, advanced imaging for under 21, and various pharmaceuticals effective April 1, 2026.
Action Required
Immediately: Update billing system for incontinence supplies codes (T4521-T4543) to require PA only when exceeding 186 units/month or $165 monthly limit. By March 31, 2026: Configure prior authorization requirements for new codes including genetic testing (0616U-0630U), CT imaging for under 21 (G0680), neuro stimulators (C8007-C8012), and various pharmaceuticals. Update encounter forms and train staff on new PA requirements. Note: J9003 (Camcevi) does not require PA for urology/hematology. Contact CalViva Health at 888-893-1569 with questions.