MedicaidAdministrativeHigh impact
23-196m Changes to Endoscopy Matrix
Health Net·CA · Gastroenterology, Pulmonology, Urology +1 more·Prior Authorization
Effective date
Jan 1, 2023
We identified it
Jun 20, 2026
Summary
The Endoscopy Matrix has been updated to classify 14 new CPT codes as either diagnostic testing or therapeutic (surgical) procedures, affecting the division of financial responsibility between the health plan and capitated providers. ASCs and hospitals must now refer to the updated matrix to determine which payer is financially responsible for these endoscopic procedures before rendering services.
Action Required
Immediately: Billing team must download the updated Endoscopy Matrix from the Provider Library and update billing system to reflect the new classification of 14 endoscopy CPT codes. ASCs and hospitals must verify financial responsibility using the matrix before rendering services and ensure claims are submitted to the appropriate payer (plan vs. capitated provider) based on the diagnostic vs. therapeutic classification.