Medicare AdvantagePrior AuthHigh impact
26-876sum Summary Update: Updates to Prior Authorization Requirements
Health Net·CA·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Jul 28, 2026
Summary
Health Net California has updated prior authorization (PA) requirements effective July 1 – October 1, 2026, with specific code list changes across three implementation phases. Billing teams must review the complete policy document (26-876) to identify which billing codes now require PA or have been removed from PA requirements, then update systems and workflows accordingly for all affected Health Net plans.
Action Required
REQUIREMENTS:
- By June 15, 2026: Obtain and review complete policy document 26-876 from Health Net Provider Library to identify specific CPT/HCPCS/ICD-10 codes with PA requirement changes. Billing team must access Provider Library > select applicable line of business (Medi-Cal Fee-for-Service, Health Net Commercial – California, or Medicare – California) > Updates and Notices > search 26-876.
- By June 20, 2026: Billing team and clinical staff must compare current internal PA code lists against all three effective date phases (July 1, July 28, and October 1, 2026) and identify which procedures your practice performs.
- By June 28, 2026: Update billing software and encounter forms to reflect new PA requirements. Add codes requiring NEW PA requests and remove codes no longer requiring PA. Configure system to automatically flag claims for PA submission based on updated rules.
- Effective July 1, 2026: Begin submitting PA requests for all newly added codes per the policy. Providers must verify member eligibility and benefits BEFORE service delivery. Front desk and clinical staff must ensure PA is obtained before scheduling/performing applicable services.
- By July 25, 2026: Prepare for July 28 phase changes; repeat code list review and system updates for that effective date.
- By September 30, 2026: Prepare for October 1 phase changes and execute final system/workflow updates.
- Ongoing: Use only current PA requirements from Health Net when submitting requests. Note that PA requirement changes do NOT guarantee benefit coverage—coverage is determined separately. Failure to obtain required PA will result in claim denials.