MedicaidPrior AuthMedium impact
20-1016 Stay Current on Transgender Service Request Rules
Health Net·CA · Family Medicine, Internal Medicine, Endocrinology +5 more·Provider News
Effective date
Oct 26, 2020
We identified it
Jun 20, 2026
Summary
New guidelines require all transgender service requests in Medi-Cal (Fresno, Kings, Madera counties) to be analyzed under both medical necessity for gender dysphoria treatment AND reconstructive surgery criteria. Approval can be based on meeting either standard, with appropriate supporting documentation required from qualified providers.
Action Required
Immediately: Billing team must update prior authorization processes for transgender services to evaluate requests under both medical necessity for gender dysphoria AND reconstructive surgery criteria. Ensure supporting documentation from qualified providers (primary care, mental health professionals, surgeons with transgender healthcare experience) is collected before submission. Contact CalViva Health at 1-888-893-1569 for questions. Applies only to Medi-Cal members in Fresno, Kings, and Madera counties.