MedicaidPrior AuthMedium impact
25-1146m Support Member Needs With New CBAS and LTC Forms
Health Net·CA · Family Medicine, Internal Medicine, Geriatrics·Prior Authorization
We identified it
Jun 20, 2026
Summary
Health Net updated two prior authorization forms effective immediately: the CBAS Treatment Request Form and LTC Authorization Notification Form. The LTC form removed confusing 'Level A and B' terminology and now uses clearer language for nursing facility care requests.
Action Required
Immediately: Access updated CBAS Treatment Request Form and LTC Authorization Notification Form from Health Net's Medi-Cal Provider Library. Update workflow to use new CBAS form for face-to-face assessment requests (fax to 833-581-5908) and new LTC form without Level A/B designations (fax to 855-851-4563). Staff must add 'PROTECTED HEALTH INFORMATION' cover sheets when faxing forms with PHI.