MedicaidPrior AuthHigh impact
21-142 Medical Policies - 4th Quarter 2020
Health Net·CA · Hematology, ENT (Ear, Nose & Throat), Wound Care +13 more·Prior Authorization
We identified it
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.
Action Required
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.