MedicaidReimbursementHigh impact
23-819 Bill Correctly to Get Paid-New Payment Edits to Be Added
Health Net·CA · OB-GYN, Diagnostic Imaging, Ophthalmology +1 more·Reimbursement
Effective date
Oct 19, 2023
We identified it
Jun 20, 2026
Summary
Health Net is implementing new claim edits (PRDM and PEDM) effective October 19, 2023, that will automatically review procedure and diagnosis code combinations to ensure compliance with California Medi-Cal billing guidelines. Claims with improper code combinations will be flagged or denied based on state Medicaid rules.
Action Required
By October 19, 2023: Billing team must review all claims using the listed CPT codes to ensure procedure and diagnosis code combinations comply with California Medi-Cal guidelines. Verify that diagnosis codes support the procedures being billed and that no excluded diagnoses are paired with restricted procedure codes. Update billing software validation rules if possible and train staff on proper code pairing for these high-risk procedure codes to prevent claim denials.