MedicaidAdministrativeHigh impact
26-643 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. Billing teams must identify carved-out medications and route claims to the correct Medi-Cal payer to avoid denials and rework.
Action Required
Before July 27, 2026: Billing team must review all Medi-Cal medication claims to identify carved-out medications using DHCS resources. Update billing workflows to route pharmacy carved-out medications to Medi-Cal Rx and medical/institutional carved-out medications to Medi-Cal Fee-for-Service. Do not submit these claims to Health Net. Train staff on the Medi-Cal Rx carve-out scope document and update billing system rules. Claims submitted incorrectly to Health Net will be denied and require resubmission to the appropriate Medi-Cal payer.