MedicaidPrior AuthHigh impact
26-824 Follow New Maternity Care Requirements to Avoid Claim Delays
Health Net·CA · OB-GYN, Family Medicine, General Practice·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jul 3, 2026
Summary
Medi-Cal has implemented new maternity care requirements effective January 1, 2026, requiring providers to complete risk assessments at initial visit, each trimester, and postpartum; document screening results and patient opt-outs for the California Prenatal Screening Program; and offer referrals to behavioral health, lactation, doula, and Community Health Worker services. Prior authorization is now required for basic prenatal, maternal, and preventive services with standard turnaround of 5 business days (not to exceed 7 calendar days) or 72 hours for urgent cases. Claims may be delayed if documentation and opt-out status are not properly recorded.
Action Required
By December 31, 2025: Billing and clinical teams must implement the following changes: (1) Update EHR/billing system to require prior authorization for all basic prenatal, maternal, and preventive services with documented authorization timelines (5 business days standard, 72 hours urgent). (2) Modify encounter templates to include checkboxes for risk assessments at initial visit, each trimester, and postpartum visits. (3) Add required documentation fields for depression screening, intimate partner violence screening, and California Prenatal Screening Program education/opt-out status. (4) Train providers and front-desk staff to document patient opt-out decisions and include opt-out status on all claims to prevent processing delays. (5) Update referral workflows to include behavioral health care, lactation services, doula services, and Community Health Worker services for all pregnant patients. Failure to obtain prior authorization and properly document screening opt-outs will result in claim processing delays. Additional care coordination requirements take effect July 1, 2026.