MedicaidPrior AuthHigh impact
25-997 Streamlining Prior Authorization: Simplifying Processes for Better Efficiency
Health Net·CA · Psychiatry, General Surgery, Cardiology +5 more·Prior Authorization
Effective date
Dec 1, 2025
We identified it
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.
Action Required
By December 1, 2025: Billing team must update prior authorization requirements in billing system and encounter forms for all affected codes. Remove PA requirements for codes including genetic testing (81244, 81331), oxygen (E0441), skin grafts (15240-15777), and elective pediatric surgeries (69705, 69706). Maintain 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). Staff should access updated PA requirements via Provider Library > Medi-Cal > Prior Authorization Requirements.