What do I need to do?

Immediately: Review all updated medical policies listed in this Q4 2020 update. Billing team must verify prior authorization requirements for oxygen therapy services, ambulatory surgery center procedures, bariatric surgery, and other affected services. Update billing system rules to reflect new coverage criteria and code changes. Remove HCPCS Q4111 from wound care billing. Verify ASC redirection requirements are properly configured. Ensure documentation requirements meet updated medical necessity criteria for all listed procedures.

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Health NetMedicaid · Prior Auth · Prior Authorization · CA · Hematology, ENT (Ear, Nose & Throat), Wound Care +13 moreHigh impact

21-142 Medical Policies - 4th Quarter 2020

Q: Who is affected by this change?

This affects Health Net Hematology, ENT (Ear, Nose & Throat), Wound Care, Pediatrics, Oncology, Radiology +10 more providers in CA on Medicaid plans.

Q: Which billing codes are affected?

The following codes are affected: Q4111, A39.82, H35.54, R44.1, R48.3, H54.7, C15.3, C15.4, C15.5, C15.8, C15.9, C37, C71.0, C71.1, C71.2, C71.3, C71.4, C71.5, C71.6, C71.7, C71.8, C71.9, C72.0, C72.1, C72.2, C72.3, C72.4, C72.5, C72.8, C72.9, N40.1, R35.1, 51798, M17.0, M17.1, M17.2, M17.3, M17.4, M17.5, M17.9, M19.171, M19.172, M19.173, M19.174, M19.175, M19.176, M19.177, M19.178, M19.179, M19.271, M19.272, M19.273, M19.274, M19.275, M19.276, M19.277, M19.278, M19.279.

Act

immediately

Effective date

Not stated in the notice

Identified

Jun 20, 2026

Summary

CalViva Health updated multiple medical policies for Q4 2020 affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties. Key changes include revised oxygen therapy criteria, new ambulatory surgery center redirection requirements, updated bariatric surgery protocols, and modified coverage for various diagnostic and therapeutic services.

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What to do

immediately · 6 steps

01Review all updated medical policies listed in this Q4 2020 update.

02Billing team must verify prior authorization requirements for oxygen therapy services, ambulatory surgery center procedures, bariatric surgery, and other affected services.

03Update billing system rules to reflect new coverage criteria and code changes.

04Remove HCPCS Q4111 from wound care billing.

05Verify ASC redirection requirements are properly configured.

06Ensure documentation requirements meet updated medical necessity criteria for all listed procedures.

Codes mentioned

Q4111A39.82H35.54R44.1R48.3H54.7C15.3C15.4C15.5C15.8C15.9C37C71.0C71.1C71.2C71.3C71.4C71.5C71.6C71.7C71.8C71.9C72.0C72.1C72.2C72.3C72.4C72.5C72.8C72.9N40.1R35.151798M17.0M17.1M17.2M17.3M17.4M17.5M17.9M19.171M19.172M19.173M19.174M19.175M19.176M19.177M19.178M19.179M19.271M19.272M19.273M19.274M19.275M19.276M19.277M19.278M19.279

Original notice

21-142 Medical Policies - 4th Quarter 2020

providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.

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Related changes

See all Health Net changes →

21-139 Medical Policies - 4th Quarter 2020HighNo effective date · Prior Authorization 21-141 Medical Policies - 4th Quarter 2020HighNo effective date · Prior Authorization 20-219 Medical Policies - 4th Quarter 2019HighNo effective date · Prior Authorization 20-220 Medical Policies - 4th Quarter 2019HighNo effective date · Prior Authorization Browse every Health Net change in the policy list

Related policy hubs

Health Net policies CA policy changes Hematology ENT (Ear, Nose & Throat)Wound Care Pediatrics Oncology Radiology Urology Allergy & Immunology Physical Therapy Bariatric Surgery Cardiology General Surgery Occupational Therapy Endocrinology Speech Therapy Pulmonology Code Q4111 Code A39.82 Code H35.54 Code R44.1 Code R48.3 Code H54.7 Code C15.3 Code C15.4 Code C15.5 Code C15.8 Code C15.9 Code C37 Code C71.0 Code C71.1 Code C71.2 Code C71.3 Code C71.4 Code C71.5 Code C71.6 Code C71.7 Code C71.8 Code C71.9 Code C72.0 Code C72.1 Code C72.2 Code C72.3 Code C72.4 Code C72.5 Code C72.8 Code C72.9 Code N40.1 Code R35.1 Code 51798 Code M17.0 Code M17.1 Code M17.2 Code M17.3 Code M17.4 Code M17.5 Code M17.9 Code M19.171 Code M19.172 Code M19.173 Code M19.174 Code M19.175 Code M19.176 Code M19.177 Code M19.178 Code M19.179 Code M19.271 Code M19.272 Code M19.273 Code M19.274 Code M19.275 Code M19.276 Code M19.277 Code M19.278 Code M19.279

21-142 Medical Policies - 4th Quarter 2020

Summary

Get alerts when payers change rules like this one

What to do

Codes mentioned

Original notice

Related changes

Related policy hubs

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