MedicaidAdministrativeMedium impact
23-389 Arrange for Covered Services When Services Are Not Available from Contracted Providers
Health Net·CA·Prior Authorization
We identified it
Jun 20, 2026
Summary
CalViva Health must now actively arrange appointments with out-of-network providers when contracted providers cannot meet timely access requirements for medically necessary services. The plan is responsible for contacting non-contracted providers and scheduling appointments, not just providing member referrals.
Action Required
Immediately: Billing team should verify that CalViva Health has arranged and pre-authorized any out-of-network services before providing care. Contact CalViva at 888-893-1569 to confirm arrangement status for out-of-network referrals. Document that services were arranged by the plan to ensure proper reimbursement.