26-1037 Order Prenatal Screening Through Approved Programs and In-Network Laboratories

Immediately: (1) Billing team must update system rules to deny authorization requests submitted to CalViva Health Plan for CPT 81420—this service is carved out and requires CDPH Prenatal Screening Program ordering only. (2) Providers must be instructed to order CPT 81420 exclusively through the California Department of Public Health Prenatal Screening Program using only state-supported laboratories per CDPH resources. (3) Do not order or bill CPT 0449U (BillionToOne prenatal carrier screening panel); this is not a covered Medi-Cal benefit and will result in claim denials. (4) For standard prenatal carrier screening, ensure billing team enforces use of in-network laboratories (Labcorp, Quest Diagnostics) and validates applicable CPT codes per Plan requirements before processing claims. Update encounter forms and billing system rules to reflect these requirements. Failure to follow these requirements will result in claim denials, payment delays, and processing issues for Medi-Cal members in these three counties. Contact CalViva Health at 888-893-1569 for coverage, coding, or in-network laboratory questions.