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25-997 Streamlining Prior Authorization: Simplifying Processes for Better Efficiency
Act
by Dec 1, 2025
Effective date
Dec 1, 2025
Identified
Jun 20, 2026
Summary
Community Health Plan of Imperial Valley is updating prior authorization requirements effective December 1, 2025, removing PA requirements for many services including genetic testing, oxygen supplies, and various surgical procedures, while maintaining or adding PA requirements for specific services like TMS therapy and certain hernia repairs.
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What to do
by Dec 1, 2025 · 4 steps
01Billing team must update prior authorization requirements in billing system and encounter forms for all affected codes.
02Remove PA requirements for codes including genetic testing (81244, 81331), oxygen (E0441), skin grafts (15240-15777), and elective pediatric surgeries (69705, 69706).
03Maintain PA requirements for TMS therapy (90867, 90868), incontinence supplies (T4521-T4524), specific pharmaceuticals (J3420, J1944, J2426, J2427), hernia repairs (49591, 49593, 49595, 49650), cardiovascular procedure (37243), nervous system procedure (64999), and non-emergency medical transportation (A0428).
04Staff should access updated PA requirements via Provider Library > Medi-Cal > Prior Authorization Requirements.
Codes mentioned
9086790868T4521T4522T4523T4524A4239E0441J3420J1944J2426J24278124481331S5111S9342S9343S91251524015241152601526115272157773724349591495934959549650649996970569706119001190136471364791310013101131021312013121131221315113152A0428
Original notice
25-997 Streamlining Prior Authorization: Simplifying Processes for Better Efficiency
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
Related changes
See all Health Net changes →25-996 Streamlining Prior Authorization: Simplifying Processes for Better EfficiencyMediumEffective Dec 1, 2025 · Prior Authorization25-998 Streamlining Prior Authorization: Simplifying Processes for Better EfficiencyHighEffective Dec 1, 2025 · Prior Authorization25-999 Streamlining Prior Authorization: Simplifying Processes for Better EfficiencyMediumEffective Dec 1, 2025 · Prior Authorization26-629 Updates to Prior Authorization RequirementsHighEffective Apr 1, 2026 · Prior AuthorizationBrowse every Health Net change in the policy list
Related policy hubs
Health Net policiesCA policy changesPsychiatryGeneral SurgeryCardiologyNeurosurgeryDermatologyVascular SurgeryWound CareENT (Ear, Nose & Throat)Code 90867Code 90868Code T4521Code T4522Code T4523Code T4524Code A4239Code E0441Code J3420Code J1944Code J2426Code J2427Code 81244Code 81331Code S5111Code S9342Code S9343Code S9125Code 15240Code 15241Code 15260Code 15261Code 15272Code 15777Code 37243Code 49591Code 49593Code 49595Code 49650Code 64999Code 69705Code 69706Code 11900Code 11901Code 36471Code 36479Code 13100Code 13101Code 13102Code 13120Code 13121Code 13122Code 13151Code 13152Code A0428