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Health NetMedicaid · Prior Auth · Prior Authorization · CA · Urology, Oncology, Hematology +3 moreMedium impact

26-631 Updates to Prior Authorization Requirements

Act
immediately
Effective date
Apr 1, 2026
Identified
Jun 20, 2026

Summary

LA-DHS Medi-Cal updated prior authorization requirements with immediate changes for incontinence supplies (PA only required beyond 186 units/month or $165/month limit) and new PA requirements effective April 1, 2026 for multiple services including genetic testing, gene therapy drugs, orthotics, prosthetics, and neuro stimulators.

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What to do

immediately · 4 steps
01Update billing system to only require PA for incontinence supplies (T4521-T4533, T4543) when exceeding 186 units/month or $165/month limit.
02By March 31, 2026: Program billing system to require prior authorization for all listed genetic testing codes (0614U-0630U), gene therapy drugs (C9309, J3404, J9183, J9277, J9601), immune globulin (J1553), denosumab agents (Q5161-Q5162), custom orthotics (A8005-A8006), prosthetics (L5992), and neuro/spinal cord stimulators (C8007, C8008, C8011, C8012).
03Note: J9003 Camcevi does NOT require PA for urology/hematology.
04Claims submitted without required PA will be denied.

Codes mentioned

T4521T4522T4523T4524T4525T4526T4527T4528T4529T4530T4533T4543C9309J1553J3404J9003J9183J9277J9601Q5161Q5162A8005A8006L5992C8007C8008C8011C8012

Original notice

26-631 Updates to Prior Authorization Requirements
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
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Related changes

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26-629 Updates to Prior Authorization RequirementsHighEffective Apr 1, 2026 · Prior Authorization26-628 Updates to Prior Authorization RequirementsMediumEffective Apr 1, 2026 · Prior Authorization26-630 Updates to Prior Authorization RequirementsHighEffective Apr 1, 2026 · Prior Authorization26-073 Updates to the Prior Authorization RequirementsHighEffective Apr 1, 2026 · Prior AuthorizationBrowse every Health Net change in the policy list

Related policy hubs

Health Net policiesCA policy changesUrologyOncologyHematologyOrthopedicsPM&R (Physical Medicine & Rehab)NeurologyCode T4521Code T4522Code T4523Code T4524Code T4525Code T4526Code T4527Code T4528Code T4529Code T4530Code T4533Code T4543Code C9309Code J1553Code J3404Code J9003Code J9183Code J9277Code J9601Code Q5161Code Q5162Code A8005Code A8006Code L5992Code C8007Code C8008Code C8011Code C8012

Summaries are AI-assisted. Always confirm against the original payer notice.

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