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26-1000 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. The policy clarifies that 1 unit equals 1 hour of covered ECM service, specifies which activities are billable versus non-billable, and requires providers to maintain detailed documentation to support appeals of denied claims.
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What to do
by Oct 15, 2026 · 9 steps
01Billing team must implement controls in billing software to enforce the 10-unit monthly limit on ECM claims and configure system to automatically deny claims exceeding this threshold.
02Providers must review service delivery practices to ensure only covered ECM activities are billed (e.g., care coordination, assessments, care plan management, referrals, appointment assistance).
03Stop billing non-covered services including physical transportation, housing navigation, medical care/prescribing, routine appointment accompaniment, and standalone interpretation services.
04Establish documentation protocols requiring providers to record: (1) time spent on each covered service, (2) ECM activity type, and (3) team member identification for each billable unit.
05Apply standard Medicare rounding rules when converting minutes to billable hours.
06Maintain all supporting documentation for audit requests.
07Train all ECM billing staff on the new monthly limit, covered versus non-covered activities, and documentation requirements.
08For claims denied due to exceeding the monthly limit, prepare appeal submissions with detailed service evidence, time documentation, and provider identification.
09Consequence: Claims exceeding 10 units per member per month will be automatically denied.
Codes mentioned
G9008G9012G9007
Original notice
26-1000 ECM Billing Limits Take Effect October 15, 2026
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
Related changes
See all Health Net changes →26-999 ECM Billing Limits Take Effect October 15, 2026HighEffective Oct 15, 2026 · Prior Authorization26-1001 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