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26-628 Updates to Prior Authorization Requirements
Act
immediately
Effective date
Apr 1, 2026
Identified
Jun 20, 2026
Summary
CalViva Health updated prior authorization requirements effective immediately for incontinence supplies (PA only required beyond 186 units/month or $165 benefit limit) and added PA requirements for multiple new services including genetic testing, advanced imaging for under 21, and various pharmaceuticals effective April 1, 2026.
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What to do
immediately · 5 steps
01Update billing system for incontinence supplies codes (T4521-T4543) to require PA only when exceeding 186 units/month or $165 monthly limit.
02By March 31, 2026: Configure prior authorization requirements for new codes including genetic testing (0616U-0630U), CT imaging for under 21 (G0680), neuro stimulators (C8007-C8012), and various pharmaceuticals.
03Update encounter forms and train staff on new PA requirements.
04Note: J9003 (Camcevi) does not require PA for urology/hematology.
05Contact CalViva Health at 888-893-1569 with questions.
Codes mentioned
T4521T4522T4523T4524T4525T4526T4527T4528T4529T4530T4533T4543G0680C8007C8008C8011C8012J9183J9277J9601J9003J1553Q5161Q5162J3404C9309A8005A8006L5992A2040A2041A2042A2043A2044A2045G0681G0682G0683G0684Q4418Q4419Q4421Q4422Q4423Q4424Q4425Q4426Q4427Q4428Q4429Q4435Q4436Q4437Q4438Q4439Q4440
Original notice
26-628 Updates to Prior Authorization Requirements
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
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