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CommercialPrior AuthHigh impact

26-075 Updates to the Prior Authorization Requirements

Health Net·CA · Plastic Surgery, Orthopedics, Cardiology +9 more·Prior Authorization
Effective date
Apr 1, 2026
We identified it
Jun 20, 2026
Days to comply
—

Summary

Health Net is updating prior authorization requirements effective April 1, 2026, adding PA requirements for multiple procedures including reconstructive surgery, cardiac procedures, neurostimulators, and EEGs while removing PA requirements for pediatric surgeries, wound care, and certain DME items. These changes affect Commercial, Medi-Cal, and Medicare plans with the goal of reducing administrative burden.

Action Required

Action needed
By April 1, 2026: Billing team must update prior authorization workflows for Health Net plans. Add PA requirements for codes including reconstructive surgery (15734, 15736, 15738), cardiac procedures (37232, 37236-37239, 37246-37249, 92921), neurostimulators (64555, 64561, 64568), EEGs (95700-95726), and hyperbaric oxygen therapy (99183, G0277). Remove PA requirements for pediatric surgeries (11105-11107, 26055, 29848, etc.), wound care (13131-13133, 97602-97610), and ophthalmology cataract procedures (66982, 66984). Update billing system rules and provider encounter forms. Access current PA requirements via Health Net Provider Library.

Affected Billing Codes

15734
15736
15738
25111
29848
36482
37799
J0485
14060
21235
31254
31256
31267
25447
37232
37236
37237
37238
37239
37246
37247
37248
37249
58545
60240
60252
60500
64555
64561
64568
92921
95700
95712
95713
95714
95715
95716
95718
95720
95721
95722
95723
95724
95725
95726
99183
G0277
99199
B4104
B4105
T4525
T4526
T4527
T4528
T4529
T4530
T4533
T4543
L5652
11105
11106
11107
26055
52000
52005
52204
52351
54161
54640
64718
64719
64721
A4322
E0600
E0730
E0950
E0956
L2330
L8420
L8440
L8470
L8480
L8485
13131
13132
13133
13153
13160
97602
97605
97606
97607
97608
97610
S0265
E0185
E0486
L1951
K0738
J1096
81256
66982
66984

Related policy hubs

Health Net policiesCA policy changesPlastic SurgeryOrthopedicsCardiologyGeneral SurgeryUrologyNeurologyWound CareOphthalmologyENT (Ear, Nose & Throat)EndocrinologyOB-GYNPediatricsCode 15734Code 15736Code 15738Code 25111Code 29848Code 36482Code 37799Code J0485Code 14060Code 21235Code 31254Code 31256Code 31267Code 25447Code 37232Code 37236Code 37237Code 37238Code 37239Code 37246Code 37247Code 37248Code 37249Code 58545Code 60240Code 60252Code 60500Code 64555Code 64561Code 64568Code 92921Code 95700Code 95712Code 95713Code 95714Code 95715Code 95716Code 95718Code 95720Code 95721Code 95722Code 95723Code 95724Code 95725Code 95726Code 99183Code G0277Code 99199Code B4104Code B4105Code T4525Code T4526Code T4527Code T4528Code T4529Code T4530Code T4533Code T4543Code L5652Code 11105Code 11106Code 11107Code 26055Code 52000Code 52005Code 52204Code 52351Code 54161Code 54640Code 64718Code 64719Code 64721Code A4322Code E0600Code E0730Code E0950Code E0956Code L2330Code L8420Code L8440Code L8470Code L8480Code L8485Code 13131Code 13132Code 13133Code 13153Code 13160Code 97602Code 97605Code 97606Code 97607Code 97608Code 97610Code S0265Code E0185Code E0486Code L1951Code K0738Code J1096Code 81256Code 66982Code 66984