MedicaidPrior AuthHigh impact
25-1213m 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
Major updates to prior authorization requirements for Applied Behavioral Analysis (ABA) therapy, Assisted Reproductive Technology, and Bariatric Surgery effective October 2025. Key changes include stricter documentation requirements for ABA therapy (limiting to 6 hours/day, 30 hours/week), addition of assisted hatching coverage for fertility treatments, 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 therapy to enforce new 30-hour weekly limits and require additional documentation for sessions exceeding 6 hours/day. Add CPT 43999 to bariatric surgery billing codes for SADI-S procedures. Update prior auth forms to include new ABA assessment requirements including diagnostic interviews within 12 months if comprehensive evaluation is 3-5 years old. Providers must document crisis plans, school-based criteria, and parent/caregiver training for all ABA requests.