MedicaidPrior AuthMedium impact
20-561 Review New Requirements for Private Duty Nursing for Medi-Cal Members Under Age 21
Health Net·CA · Pediatrics, Family Medicine·Prior Authorization
We identified it
Jun 20, 2026
Summary
Health Net/CalViva Health now requires prior authorization for all private duty nursing (PDN) services for Medi-Cal members under age 21, with mandatory case management referrals. Direct Network providers must use a specific prior authorization form and fax process, while PPG providers follow their group's authorization process.
Action Required
Immediately: For any Medi-Cal members under 21 requiring private duty nursing services, billing team must ensure providers obtain prior authorization before services begin. Direct Network providers must complete Request for Prior Authorization form and fax to 1-800-743-1655 with clinical documentation. All approved PDN cases require case management referral via email to CASHP.ACM.CMA@healthnet.com or fax to 1-866-581-0540. For CCS-eligible conditions, submit Service Authorization Request to local CCS program office instead.