MedicaidPrior AuthHigh impact
25-249 Refer Members to In-Network Providers to Minimize Out-of-Pocket Costs
Health Net·CA·Prior Authorization
We identified it
Jun 20, 2026
Summary
New policy requires providers to refer members to in-network providers whenever possible to minimize out-of-pocket costs. Out-of-network referrals are only reimbursed for emergencies, legal requirements, or when prior authorization is obtained in advance.
Action Required
Immediately: All providers and front desk staff must prioritize in-network referrals for all specialty consultations. Use the Find a Provider tool at Provider Search before making referrals. For any necessary out-of-network referrals, contact Plan Provider Services (CHPIV Medi-Cal: 833-236-4141, Behavioral Health: 844-966-0298) to verify necessity and obtain prior authorization before the referral. Update referral workflows to include network status verification.