Medicare AdvantagePrior AuthHigh impact
24-649 Medi-Cal Covered Services Not Covered Under Medicare for DSNP Members in Exclusively Aligned Counties
Health Net·CA·Prior Authorization
Effective date
Oct 28, 2024
We identified it
Jun 20, 2026
Summary
For Dual Special Needs Plan (DSNP) members in specific California counties, participating physician groups must now forward prior authorizations for services not covered by Medicare but covered by Medi-Cal to Health Net instead of denying them. This applies to services like personal care, home modifications, and medically tailored meals in Fresno, Kings, Madera, Los Angeles, Sacramento, and Tulare counties.
Action Required
Immediately: Billing team must update prior authorization workflow for DSNP members in California EAE counties (Fresno, Kings, Madera, Los Angeles, Sacramento, Tulare). For services not covered by Medicare but covered by Medi-Cal, forward standard requests to Health Net within 1 business day and expedited requests within 24 hours via fax 800-743-1655. Include original receipt date/time and clinical decision. Do not deny as 'not covered' without checking both Medicare and Medi-Cal benefits. Update staff training on integrated determination process.