MedicaidPrior AuthHigh impact
26-874sum Summary Update: Updates to Prior Authorization Requirements
Health Net·CA·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Jul 28, 2026
Summary
CalViva Health (Medi-Cal) has updated prior authorization requirements effective July 1, October 1, and July 28, 2026, with code-level additions and removals. Billing teams must review the complete policy document (26-874) to identify which specific services now require or no longer require prior authorization and update submission workflows accordingly for Fresno, Kings, and Madera counties.
Action Required
REQUIREMENTS:
- By June 30, 2026: Billing team must obtain and review the complete policy update 26-874 from the Provider Library (Medi-Cal > Updates and Notices section) to identify ALL affected billing codes with new or removed prior authorization requirements.
- By June 30, 2026: Update billing software and EMR systems with new prior authorization requirements for affected codes effective July 1, 2026.
- By July 27, 2026: Update systems for any additional prior authorization changes effective July 28, 2026.
- By September 30, 2026: Update systems for additions and removals effective October 1, 2026.
- Billing team must verify member eligibility and benefits BEFORE providing any services.
- Providers must use current PA requirements when submitting all requests to CalViva Health.
- Update all encounter forms and clinical workflows to reflect which codes now require prior authorization.
- CONSEQUENCE: Claims submitted without required prior authorization or with outdated PA requirements will be denied. Authorization requirements are separate from coverage determinations.