CommercialPrior AuthMedium impact
25-1212m Updates to Clinical Policies - October 2025
Health Net·CA · Psychiatry, General Surgery, OB-GYN·Prior Authorization
Effective date
Oct 1, 2025
We identified it
Jun 20, 2026
Summary
Health Net updated clinical policies for Applied Behavioral Analysis (ABA), Assisted Reproductive Technology, and Bariatric Surgery effective October 2025. Key changes include stricter ABA prior authorization requirements with new diagnostic evaluation timelines, addition of assisted hatching coverage for infertility treatment, and expanded bariatric surgery options including SADI/SADI-S procedures.
Action Required
Before October 1, 2025: Billing team must update prior authorization workflows for ABA services to include new diagnostic evaluation requirements (within 12 months if CDE was 3-5 years ago), ensure comprehensive diagnostic evaluation documentation is complete, and add CPT 43999 for SADI-S bariatric procedures. Update encounter forms to reflect new ABA treatment hour limits (maximum 6 hours/day, 30 hours/week) and supervision requirements (minimum 2 hours/week or 10% of direct service).