MedicaidPrior AuthHigh impact
25-731m Medical Policies - June 2025
Health Net·CA · Hematology, Pain Management, Gastroenterology +5 more·Prior Authorization
Effective date
Jun 1, 2025
We identified it
Jun 20, 2026
Summary
Multiple medical policies have been updated with changes to prior authorization criteria, coverage requirements, and documentation standards across 10 different specialties. Key changes include expanded coverage for certain procedures, relaxed criteria for some treatments, and updated coding requirements.
Action Required
By June 1, 2025: Billing team must review and update prior authorization workflows for all affected procedures including hematopoietic cell therapy, epidural injections, facet joint interventions, fecal incontinence treatments, fetal surgery, GI pathogen testing, pediatric liver transplant, pulmonary function testing, reduction mammoplasty, and artificial heart procedures. Update billing system to include new CPT codes 44320, 0369U and HCPCS codes C1767, C1778. Train staff on revised medical necessity criteria to prevent claim denials.