MedicaidAdministrativeHigh impact
23-818 Bill Correctly to Get Paid - New Payment Edits to Be Added
Health Net·CA · Diagnostic Imaging, OB-GYN, Ophthalmology·Prior Authorization
Effective date
Oct 19, 2023
We identified it
Jun 20, 2026
Summary
Health Net CalViva Health is implementing new claim edits effective October 19, 2023, that will automatically review procedure and diagnosis code combinations to ensure compliance with California Medi-Cal billing rules. Two new edits (PRDM and PEDM) will check if procedures and diagnoses can be billed together or if certain diagnosis codes are disallowed with specific procedure codes.
Action Required
By October 19, 2023: Billing team must review all claims using the listed procedure codes to ensure diagnosis codes comply with California Medi-Cal billing guidelines. Verify procedure-diagnosis combinations are allowable before submitting claims. Update claim review processes to check for PRDM and PEDM edit requirements. Monitor claim rejections and use CalViva Health provider portal for real-time claim status. Claims with non-compliant code combinations will be rejected.