MedicaidPrior AuthHigh impact
26-825 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 have been updated effective January 1, 2026, requiring providers to complete risk assessments at specific intervals, document screening results and patient opt-outs, provide prenatal education, and coordinate expanded support services (doula, lactation, behavioral health). Prior authorization is now required for basic prenatal, maternal, and preventive services with 5-7 business day standard timelines. Failure to comply will result in claim processing delays.
Action Required
By December 31, 2025: (1) Billing team must update claim submission processes to require prior authorization for all basic prenatal, maternal, and preventive services under Medi-Cal in Fresno, Kings, and Madera counties. Set authorization timelines to standard (5 business days, not to exceed 7 calendar days) and urgent (72 hours). (2) Providers must update maternity encounter forms and workflows to document: risk assessments at initial visit, each trimester, and postpartum; screening results (depression, intimate partner violence); California Prenatal Screening (PNS) Program opt-out decisions with status notation; and patient education completion. (3) Billing team must configure system to include opt-out status on claims when applicable to prevent processing delays. (4) Providers and staff must begin offering/referring patients to behavioral health, lactation services, doula services, and Community Health Worker services. (5) Credentialing and care coordination teams must prepare for July 1, 2026 requirements for Transitional Care Services. Consequences: Claims will be delayed or denied without proper prior authorization, documentation of screening/opt-outs, and education completion.