MedicaidPrior AuthHigh impact
26-629 Updates to Prior Authorization Requirements
Health Net·CA · Urology, Oncology, Neurology +3 more·Prior Authorization
Effective date
Apr 1, 2026
We identified it
Jun 20, 2026
Summary
Community Health Plan of Imperial Valley updated prior authorization requirements with immediate changes for incontinence supplies (PA only required beyond 186 units/month or $165/month limit) and extensive new PA requirements effective April 1, 2026 for multiple categories including advanced imaging, genetic testing, pharmaceuticals, and skin substitutes.
Action Required
Immediately: Update billing system to remove prior authorization requirements for incontinence supplies (T4521-T4543) unless exceeding 186 units/month or $165 monthly limit. By March 31, 2026: Program billing system to require prior authorization for all listed codes effective April 1, 2026, including CT imaging for members under 21 (G0680), genetic testing codes (0616U-0630U), neuro stimulators (C8007-C8012), new pharmaceuticals, skin substitutes, and prosthetics for members under 21. Update encounter forms and train staff on new PA requirements to prevent claim denials.