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Medi-CalMedicaid · Prior Auth · Claims & Billing · CA · Physical Therapy, Occupational Therapy, PM&R (Physical Medicine & Rehab) +1 moreHigh impact

Coverage and Billing Policy Updates for DME and Wheelchair Repairs, Maintenance and Replacement Parts, Among Other Policy Clarifications

Act
by Jul 31, 2026
Effective date
Aug 1, 2026
Identified
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.

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What to do

by Jul 31, 2026 · 5 steps
01Billing 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).
02Enable 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.
03Configure system to enforce K0462 frequency limit of 2 times per year, with TAR required to exceed this limit.
04Update billing staff training and encounter forms to reflect these threshold changes.
05Notify providers that TAR requirements have been reduced for most DME, which should decrease prior auth submissions and improve claim processing speed.
If missed: Failure to update billing system may result in incorrect TAR submissions, claim denials, or payment delays.

Codes mentioned

K0462

Original notice

Coverage and Billing Policy Updates for DME and Wheelchair Repairs, Maintenance and Replacement Parts, Among Other Policy Clarifications
mcweb.apps.prd.cammis.medi-cal.ca.gov · Always check the source before changing claims.
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Related policy hubs

Medi-Cal policiesCA policy changesPhysical TherapyOccupational TherapyPM&R (Physical Medicine & Rehab)GeriatricsCode K0462

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