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26-630 Updates to Prior Authorization Requirements
Act
immediately
Effective date
Apr 1, 2026
Identified
Jun 20, 2026
Summary
Health Net has updated prior authorization requirements with immediate changes to Medi-Cal incontinence supplies (PA only required beyond 186 units/month or $165/month limit) and new PA requirements for multiple services including advanced imaging, genetic testing, neuro stimulators, medications, and orthotics effective April 1, 2026.
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What to do
immediately · 4 steps
01Update billing system to remove prior auth requirement for Medi-Cal incontinence supplies (codes T4521-T4543) unless exceeding 186 units/month or $165 limit.
02By April 1, 2026: Configure billing software to require prior authorization for all listed codes including advanced imaging G0680, genetic testing codes 0616U-0630U, neuro stimulators C8007-C8012, orthotics A8005-A8006 and L2221, multiple outpatient pharmaceuticals, and skin substitutes.
03Update encounter forms and train staff on new PA requirements.
04Claims will be denied without proper authorization.
Codes mentioned
T4521T4522T4523T4524T4525T4526T4527T4528T4529T4530T4533T4543G0680C8007C8008C8011C8012A8005A8006L2221C9818J9278J9183J9277J9601J9003J1553Q5161Q5162J3404C9309L5992A2040A2041A2042A2043A2044A2045G0681G0682G0683G0684Q4418Q4419Q4421Q4422Q4423Q4424Q4425Q4426Q4427Q4428Q4429Q4435Q4436Q4437Q4438Q4439Q4440
Original notice
26-630 Updates to Prior Authorization Requirements
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
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Related policy hubs
Health Net policiesCA policy changesWound CareOncologyNeurologyUrologyRadiologyOrthopedicsCode T4521Code T4522Code T4523Code T4524Code T4525Code T4526Code T4527Code T4528Code T4529Code T4530Code T4533Code T4543Code G0680Code C8007Code C8008Code C8011Code C8012Code A8005Code A8006Code L2221Code C9818Code J9278Code J9183Code J9277Code J9601Code J9003Code J1553Code Q5161Code Q5162Code J3404Code C9309Code L5992Code A2040Code A2041Code A2042Code A2043Code A2044Code A2045Code G0681Code G0682Code G0683Code G0684Code Q4418Code Q4419Code Q4421Code Q4422Code Q4423Code Q4424Code Q4425Code Q4426Code Q4427Code Q4428Code Q4429Code Q4435Code Q4436Code Q4437Code Q4438Code Q4439Code Q4440