MedicaidPrior AuthHigh impact
26-826 Follow New Maternity Care Requirements to Avoid Claim Delays
Health Net·CA · OB-GYN, Family Medicine, General Practice +1 more·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jul 3, 2026
Summary
Medi-Cal maternity care requirements are now in effect requiring providers to complete risk assessments at initial visit, each trimester, and postpartum; document all screening results and patient opt-outs; provide prenatal screening education; and coordinate expanded support services (doula, lactation, behavioral health). Prior authorization is now required for basic prenatal, maternal, and preventive services with standard authorization timelines of 5 business days (max 7 calendar days). Failure to comply will result in claim processing delays.
Action Required
By December 31, 2025 (before January 1, 2026 effective date): (1) Billing team must update billing system to require prior authorization for all basic prenatal, maternal, and preventive services. Set authorization timelines: standard 5 business days (not to exceed 7 calendar days), urgent 72 hours. (2) Providers must update encounter forms and EMR templates to include mandatory fields for: risk assessment documentation (initial visit, each trimester, postpartum); screening results (depression, intimate partner violence); California Prenatal Screening (PNS) Program education documentation; and patient opt-out decisions when applicable. (3) Front desk and clinical staff must document opt-out status on all claims to prevent processing delays. (4) Billing team must train staff on new documentation requirements for claims submitted with screening conducted outside PNS Program. By July 1, 2026: Implement additional care coordination requirements including Transitional Care Services documentation. Failure to obtain prior authorization will result in claim denials; incomplete documentation will cause claim processing delays.