MedicaidPrior AuthHigh impact
25-1214m 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
CalViva Health updated three clinical policies effective October 2025, significantly expanding prior authorization requirements for Applied Behavioral Analysis (ABA) therapy, adding assisted hatching as covered under reproductive technology, and updating bariatric surgery criteria to include new procedures. The most impactful change is the detailed ABA requirements including new assessment protocols, treatment hour limits, and documentation standards.
Action Required
By October 1, 2025: Billing teams must update prior authorization workflows for ABA therapy to include new comprehensive diagnostic evaluation requirements, assessment tool documentation, and treatment hour justification (maximum 6 hours/day, 30 hours/week). Update bariatric surgery pre-authorization to include CPT 43999 for SADI-S procedures. Add assisted hatching to covered reproductive services. Train staff on new ABA documentation requirements including crisis plans, school-based criteria, and parent/caregiver training components. Failure to meet new requirements will result in authorization denials.