MedicaidBilling CodesMedium impact
25-914 Bill Correctly for HIV Pre-exposure Prophylaxis (PrEP)
Health Net·CA · Family Medicine, Internal Medicine, Infectious Disease·Prior Authorization
We identified it
Jun 20, 2026
Summary
CalViva Health has issued updated billing guidelines for HIV Pre-exposure Prophylaxis (PrEP) services. All PrEP medications and integral services must be covered without cost-sharing, and providers must use primary diagnosis code Z29.81 with specific CPT codes for proper billing to avoid payment delays.
Action Required
Immediately: Billing team must update coding protocols for PrEP services to use Z29.81 as the primary diagnosis code for all PrEP-related encounters. Update billing system to ensure no cost-sharing is applied to PrEP medications and integral services. Train staff on the specific CPT code requirements for daily oral PrEP versus long-acting injectable PrEP protocols. Update encounter forms to include proper frequency guidelines for each service type.