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Health NetMedicaid · Coverage · Prior Authorization · CAHigh impact

26-1001 ECM Billing Limits Take Effect October 15, 2026

Act
by Oct 15, 2026
Effective date
Oct 15, 2026
Identified
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.

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What to do

by Oct 15, 2026 · 5 steps
01Billing 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.
02Providers 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).
03Establish 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.
04Train 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.
05For denied claims believed to be appropriate, submit appeals through provider dispute resolution process with detailed service evidence, time documentation, and provider identification.
If missed: Failure to comply will result in automatic claim denials exceeding the 10-unit threshold.

Codes mentioned

G9008G9012G9007

Original notice

26-1001 ECM Billing Limits Take Effect October 15, 2026
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
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Related changes

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26-999 ECM Billing Limits Take Effect October 15, 2026HighEffective Oct 15, 2026 · Prior Authorization26-1000 ECM Billing Limits Take Effect October 15, 2026HighEffective Oct 15, 2026 · Prior Authorization22-1073 ECM Services Won't Need Prior Authorization in 2023MediumEffective Jan 1, 2023 · Prior Authorization22-1074 ECM Services Won't Need Prior Authorization in 2023MediumEffective Jan 1, 2023 · Prior AuthorizationBrowse every Health Net change in the policy list

Related policy hubs

Health Net policiesCA policy changesCode G9008Code G9012Code G9007

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