MedicaidPrior AuthMedium impact
22-1053m Nursing Facility Transition/Diversion Program Promotes Independent Living
Health Net·CA · Case Management, Geriatrics·Prior Authorization
We identified it
Jun 20, 2026
Summary
Health Net introduces a new Nursing Facility Transition/Diversion Program that helps members transition from nursing facilities to community-based assisted living settings. Billing teams must use service code T2038 with modifier U4 for these services and understand the prior authorization requirements for eligible members in specific California counties.
Action Required
Immediately: Billing team must add service code T2038 with modifier U4 to billing system for Nursing Facility Transition/Diversion services. Update system to flag prior authorization requirements for this service. Train staff on eligibility criteria including 60-day nursing facility stay requirement for transition services and nursing facility level of care criteria for diversion services. Only applicable for Medi-Cal members in Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.