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26-999 ECM Billing Limits Take Effect October 15, 2026
Act
by Oct 15, 2026
Effective date
Oct 15, 2026
Identified
Aug 12, 2026
Summary
Beginning 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 billing team must implement controls to ensure accurate unit reporting (1 unit = 1 hour), apply Medicare rounding rules, and maintain detailed documentation to support all billed services and appeals.
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What to do
by Oct 15, 2026 · 6 steps
01Billing team must update billing system to enforce a 10-unit monthly cap per member for ECM codes G9008 (with or without modifiers U1, GQ), G9012 (with or without modifiers U2, GQ), and G9007.
02Configure system to deny claims exceeding 10 units per calendar month.
03Providers and billing staff must implement time-tracking procedures to document ECM service hours with staff member identification and apply standard Medicare rounding rules before submission.
04Audit all current ECM service delivery practices to eliminate non-covered activities (physical transportation, housing navigation, medical prescribing, routine appointment attendance, translation services) and ensure only covered coordination activities are billed.
05Establish comprehensive documentation requirements: maintain detailed records of services provided, time spent, team member names, and care coordination activities for every billed unit.
06Create an appeals process workflow to handle denied claims exceeding the limit, with templates for submitting required evidence (service details, time documentation, staff identification) through the provider dispute resolution process.
If missed: Failure to implement these controls will result in claim denials for any ECM units exceeding 10 per member per month.
Codes mentioned
G9008G9012G9007
Original notice
26-999 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 →26-1000 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