Medicare AdvantagePrior AuthMedium impact
22-440m Submit Request for a Withdrawal or Dismissal Using Member Notification Templates
Health Net·CA·Prior Authorization
Effective date
Jan 1, 2022
We identified it
Jun 20, 2026
Summary
Health Net now requires use of standardized CMS templates when requesting withdrawal or dismissal of prior authorization requests for Medicare Advantage and Cal MediConnect plans. Providers must also report these withdrawals and dismissals in monthly data submissions using specific template fields.
Action Required
Immediately: Billing team must access new member notification templates from Health Industry Collaboration Effort (HICE) Library > Approved HICE Documents > UM Templates & Tools when requesting prior authorization withdrawals or dismissals. Update monthly data submission process to report withdrawals and dismissals using ODAG_OD template for Medicare or SARAG_MSAR template for Cal MediConnect, selecting 'withdrawal' or 'dismissed' options in the Request Determination field.