MedicaidPrior AuthMedium impact
24-1312 Delegated PPGs: Follow Requirements for Use of AI in Utilization Review and Management
Health Net·CA·Prior Authorization
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
Starting January 1, 2025, California delegated PPGs using AI for utilization review must implement new compliance requirements including written policies for AI oversight, periodic accuracy reviews, and ensuring AI tools don't make medical necessity determinations (only licensed providers can). This affects prior authorization processes in Fresno, Kings, and Madera counties.
Action Required
By January 1, 2025: Delegated PPGs in Fresno, Kings, and Madera counties must establish written policies documenting AI use in utilization review, implement periodic AI accuracy reviews, and ensure all medical necessity determinations are made by licensed physicians only (not AI tools). Review provider operations manual in CalViva Health portal and contact 888-893-1569 with questions.