MedicaidPrior AuthHigh impact
Coverage and Billing Policy Updates for DME and Wheelchair Repairs, Maintenance and Replacement Parts, Among Other Policy Clarifications
Medi-Cal·CA · Physical Therapy, Occupational Therapy, PM&R (Physical Medicine & Rehab) +1 more·Claims & Billing
Effective date
Aug 1, 2026
We identified it
Jul 10, 2026
Summary
Effective August 1, 2026, Medi-Cal is increasing TAR (Treatment Authorization Request) thresholds for DME purchases from $100 to $500 and for wheelchair repairs/maintenance from $250 to $2,500 per calendar month. Additionally, HCPCS code K0462 (temporary wheelchair replacement) is being converted from a non-standard to a standard benefit with a 2x/year frequency limit and RR modifier requirement.
Action Required
By July 31, 2026: (1) Billing team must update DME billing software to reflect new TAR thresholds—require TAR only when cumulative DME purchases exceed $500/month (up from $100) and wheelchair repair/maintenance costs exceed $2,500/month (up from $250). (2) Enable billing for HCPCS code K0462 with modifier RR as a standard benefit for temporary wheelchair rentals (one-month maximum) while patient's wheelchair is under repair/maintenance. (3) Configure system to enforce K0462 frequency limit of 2 times per year, with TAR required to exceed this limit. (4) Update billing staff training and encounter forms to reflect these threshold changes. (5) Notify providers that TAR requirements have been reduced for most DME, which should decrease prior auth submissions and improve claim processing speed. Failure to update billing system may result in incorrect TAR submissions, claim denials, or payment delays.