All PlansPrior AuthMedium impact
24-765 Non-Profit Criteria for Select Medical Behavioral Health Conditions and Substance Use Disorders
Health Net·CA · Psychiatry·Prior Authorization
Effective date
Apr 1, 2024
We identified it
Jun 20, 2026
Summary
California health plans and participating physician groups (PPGs) must now use nonprofit professional association criteria when determining medical necessity for behavioral health and substance use disorder services requiring prior authorization. This applies to services covered under members' benefit plans where PPGs are delegated for utilization management.
Action Required
Immediately: PPGs delegated for medical necessity and utilization management must update prior authorization review processes for behavioral health and substance use disorder services to use nonprofit professional association criteria for the relevant clinical specialty. Review Cal. Code Regs. Title 28 CCR § 1300.74.72.01 for specific services requiring nonprofit criteria and § 1300.74.721 for utilization review requirements. Contact Provider Engagement with questions.