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MedicaidPrior AuthMedium impact

25-996 Streamlining Prior Authorization: Simplifying Processes for Better Efficiency

Health Net·CA · Psychiatry, General Surgery, Cardiology +5 more·Prior Authorization
Effective date
Dec 1, 2025
We identified it
Jun 20, 2026
Days to comply

Summary

CalViva Health is streamlining prior authorization requirements effective December 1, 2025, removing PA requirements for several services including oxygen, genetic testing, and certain surgeries while maintaining PA for others like TMS and specific cardiovascular procedures. This affects Medi-Cal providers in Fresno, Kings, and Madera counties in California.

Action Required

Action needed
By December 1, 2025: Billing team must update prior authorization requirements in billing system for affected CPT and HCPCS codes. Remove PA requirements for oxygen (E0441), genetic testing (81244, 81331), elective surgery for ages 0-20 (69705, 69706), dermatology injections (11900, 11901), varicose vein treatment (36471, 36479), wound care procedures (13100-13152), applied behavioral analysis (S5111), enteral nutrition (S9342, S9343), respite services (S9125), and skin grafts (15240-15777). Maintain PA requirements for TMS (90867, 90868), incontinence supplies (T4521-T4524), specific pharmaceuticals (J3420, J1944, J2426, J2427), cardiovascular procedure (37243), hernia repairs (49591, 49593, 49595, 49650), nervous system procedures (64999), and non-emergency medical transportation (A0428). Update encounter forms and staff training materials.

Affected Billing Codes

90867
90868
T4521
T4522
T4523
T4524
A4239
E0441
J3420
J1944
J2426
J2427
81244
81331
S5111
S9342
S9343
S9125
15240
15241
15260
15261
15272
15777
37243
49591
49593
49595
49650
64999
69705
69706
11900
11901
36471
36479
13100
13101
13102
13120
13121
13122
13151
13152
A0428