MedicaidAdministrativeMedium impact
25-1148m Support Member Needs With New CBAS and LTC Forms
Health Net·CA·Prior Authorization
We identified it
Jun 20, 2026
Summary
Health Net updated two forms for Imperial County Medi-Cal providers: the CBAS Treatment Request Form and LTC Authorization Notification Form. The LTC form removed confusing 'Level A and B' terminology and now uses 'Nursing Facility Residential LOC 2' for custodial care.
Action Required
Immediately: Download updated CBAS Treatment Request Form and LTC Authorization Notification Form from Medi-Cal Provider Library > Forms and References. Replace old forms with new versions. For CBAS requests, fax completed forms to 833-581-5908. For LTC authorization, fax to 855-851-4563. Add 'PROTECTED HEALTH INFORMATION' cover sheet when faxing PHI. Update staff training on new LTC terminology - use 'Nursing Facility Residential LOC 2' instead of 'Level B' for custodial care.