MedicaidPrior AuthMedium impact
25-1147m Support Member Needs With New CBAS and LTC Forms
Health Net·CA · Family Medicine, Internal Medicine, General Practice +1 more·Prior Authorization
We identified it
Jun 20, 2026
Summary
Health Net/CalViva Health has updated two prior authorization forms: the CBAS Treatment Request Form and LTC Authorization Notification Form. The CBAS form can now be submitted via provider portal or fax, and the LTC form has removed confusing Level A/B terminology in favor of clearer language.
Action Required
Immediately: Billing and authorization staff must download the updated CBAS Treatment Request Form and LTC Authorization Notification Form from the Medi-Cal Provider Library. Update workflow to use new CBAS fax number 833-581-5908 and LTC fax number 855-851-4563. Train staff on new LTC terminology - no longer use 'Level A/B', now use 'Nursing Facility Residential LOC 2' for custodial care. Add PHI cover sheets when faxing forms with protected health information.