MedicaidCoverageHigh impact
26-1001 ECM Billing Limits Take Effect October 15, 2026
Health Net·CA·Prior Authorization
Effective date
Oct 15, 2026
We identified it
Aug 12, 2026
Summary
Effective October 15, 2026, Enhanced Care Management (ECM) claims are subject to a new monthly billing limit of 10 units per member per calendar month. Claims exceeding this limit will be denied. Prior authorization is not required, but billing teams must ensure accurate unit reporting (1 unit = 1 hour), maintain supporting documentation, and understand which ECM activities are covered versus non-billable.
Action Required
By October 15, 2026: (1) Billing team must implement system controls to enforce the 10-unit monthly limit per member for ECM HCPCS codes G9008, G9012, and G9007; configure billing software to flag and deny claims exceeding the limit. (2) Providers must review and adjust ECM service delivery practices to align with covered activities only (e.g., care coordination, assessments, care plan management, referrals, appointment scheduling). (3) Establish clear documentation procedures: all ECM encounters must record the specific team member providing service, time spent (in hours/units), and type of service delivered; retain all supporting documentation for audit requests. (4) Train billing and clinical staff on non-billable ECM activities (physical transportation, housing navigation, medical care provision, routine appointment attendance, translation services) to prevent claim denials. (5) For denied claims believed to be appropriate, submit appeals through provider dispute resolution process with detailed service evidence, time documentation, and provider identification. Failure to comply will result in automatic claim denials exceeding the 10-unit threshold.