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26-1201 Updates to Prior Authorization Requirements
Effective date
Jan 1, 2027
Identified
Oct 27, 2026
Summary
Health Net updated its prior authorization lists for California. Preferred and non-preferred status for the denosumab (Prolia, Xgeva and biosimilars) and ustekinumab biosimilars changed effective immediately, and several procedures and equipment codes stopped needing prior authorization for Medicare members effective November 1, 2026 (already in effect). New prior authorization requirements for wound care, scalp cooling and some outpatient drugs start January 1, 2027, and the notice says prior authorization changes do not confirm benefit coverage.
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What to do
Action · 9 steps
01Already in effect (changes were effective immediately): Providers and pharmacy staff should check the denosumab and ustekinumab tables in the notice against the preferred drug list, and update medication lists and formulary notes in the EHR so orders use the preferred biosimilars.
02Already effective November 1, 2026: For Medicare members, stop sending prior authorization requests for the codes the notice lists as removed on that date, including CPT 29848, 30520, 31256, 31267, 88271, 88275, 88280, 91110 through 91113, the DME and orthotic codes, and home health codes 99341 through 99350 and 99601 and 99602.
03Billing team: update the prior authorization tracker and front desk scheduling notes so these services are no longer held for a request.
04By January 1, 2027: Get prior authorization before scheduling wound care CPT 97605 and 97606 for Medicare members, and before scheduling scalp cooling CPT 97007, 97008 and 97009 for the plans shown as affected in the notice.
05Get authorization before administering the outpatient drugs listed as additions, including Yondelis (J9352), and check the notice's table for the plan columns that apply to each drug.
06Billing team: add the authorization number to the claim so it goes out complete.
07Also by January 1, 2027: remove prior authorization holds for CPT 21089, 40650, 40652 and 40654 for HMO members, and check provider update 26-989 for the Community Supports changes.
08Front desk and providers: verify member eligibility and benefits before providing services, because authorization does not confirm coverage.
09The notice says incomplete or incorrect requests may lead to member appeals or grievances, so submit complete requests on the first try.
Codes mentioned
97605976069700797008970092984830520312563126788271882758828091110911119111291113E0470E0471E0656E0657E0935E1032E1033E1034E1226E2310E2374E2608E2613E2622E2623E2615L0457L0650L1932L1940L1960L2330L3030140001404014041151009613096131961329613396136961379613896139961466456699341993429934499345993479934899350996019960221089406504065240654J9352
Original notice
26-1201 Updates to Prior Authorization Requirements
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
Related changes
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Related policy hubs
Health Net policiesCA policy changesOncologyPharmacyWound CareENT (Ear, Nose & Throat)OrthopedicsPulmonologyGeneticsGastroenterologyNeurologyPlastic SurgeryPM&R (Physical Medicine & Rehab)Code 97605Code 97606Code 97007Code 97008Code 97009Code 29848Code 30520Code 31256Code 31267Code 88271Code 88275Code 88280Code 91110Code 91111Code 91112Code 91113Code E0470Code E0471Code E0656Code E0657Code E0935Code E1032Code E1033Code E1034Code E1226Code E2310Code E2374Code E2608Code E2613Code E2622Code E2623Code E2615Code L0457Code L0650Code L1932Code L1940Code L1960Code L2330Code L3030Code 14000Code 14040Code 14041Code 15100Code 96130Code 96131Code 96132Code 96133Code 96136Code 96137Code 96138Code 96139Code 96146Code 64566Code 99341Code 99342Code 99344Code 99345Code 99347Code 99348Code 99350Code 99601Code 99602Code 21089Code 40650Code 40652Code 40654Code J9352