MedicaidPrior AuthHigh impact
26-958 Provider Communications Posted Online and Operations Manual Updates for July 2026
Health Net·CA · OB-GYN, Palliative Care·Prior Authorization
Effective date
Jul 24, 2026
We identified it
Aug 8, 2026
Summary
This July 2026 policy update consolidates multiple operational changes across Medi-Cal including revised prior authorization submission methods for long-term care (fax only, no email effective 7/24/26), updated hospice documentation requirements and prior auth procedures (effective 7/21/26), new encounter data submission standards (QMED 2.0), maternity benefit clarifications, and drug formulary updates. Billing teams must implement these changes immediately to avoid claim denials and compliance issues.
Action Required
REQUIREMENTS:
1. IMMEDIATE (By 7/24/2026): Billing team and prior authorization staff must cease email submissions for Long-Term Care prior authorization requests. Update all workflows, templates, and provider communications to mandate fax submission using the updated Long-Term Care Authorization Notification Form (available in Forms and References). Notify all contracted providers of this requirement. Email submissions received after 7/24/26 will cause claim processing delays and potential denials.
2. By 7/21/2026: Billing team must review and implement changes to Hospice Care prior authorization procedures. Download and train staff on the new Hospice Services Documentation Guide (PDF). Update hospice authorization request templates to reflect revised documentation requirements. Communicate new requirements to providers submitting hospice claims.
3. By 7/21/2026: Billing team and capitated providers must ensure encounter data submissions comply with QMED 2.0 requirements (Quality Measures for Encounter Data). Review updated sections: Overview, Error Notification, Noncompliance procedures, and Professional/Institutional Capitated Encounter Submission Requirements in the operations manual. Verify timely, accurate, and complete submission processes are in place. Non-compliant submissions will be rejected.
4. By 7/6/2026: Maternity billing staff must update coverage knowledge for prenatal screening and CPSP (Comprehensive Perinatal Services Program) services. Review updated Coverage Explanation and CPSP documents under Benefits > Maternity section. Ensure accurate billing for covered prenatal services per DHCS Plan Letter 26-005.
5. Ongoing: Billing team must monitor Provider Library for updates to medical policies and drug formulary. As of 7/1/26, review Medication Trend Updates and Drug List/Formulary Changes (26-784m) for 3rd Quarter 2026. As of 7/17/26, review Clinical Policies updates (26-872m) for June 2026 medical policy changes affecting prior authorization and medical necessity determinations.