MedicaidPrior AuthMedium impact
26-1200 Updates to Prior Authorization Requirements
Health Net·CA · Oncology, Rheumatology, Allergy & Immunology +1 more·Prior Authorization
Effective date
Oct 27, 2026
We identified it
Oct 27, 2026
Summary
Community Health Plan of Imperial Valley has updated prior authorization (PA) requirements for select services, medications, and equipment effective immediately and January 1, 2027. Changes include immediate updates to biosimilar medication preferred/non-preferred status, new PA requirements for gene therapy, pegfilgrastim, Yondelis®, and scalp cooling services, and removal of PA requirements for discontinued Community Supports services.
Action Required
Effective immediately (2026-10-27): Billing and clinical teams must update PA submission workflows to reflect the immediate changes to biosimilar medication preferred/non-preferred status for Denosumab and Ustekinumab agents listed in the policy; verify member eligibility and benefits before providing services. By January 1, 2027: Implement PA requirements for new services—CPT codes 97007, 97008, 97009 (scalp cooling) and J9352 (Yondelis®), as well as outpatient pharmaceuticals Kresladi™ (gene therapy) and Ennumo™ (pegfilgrastim)—in the billing system and provider PA submission processes. Simultaneously remove PA requirements for Assisted Living Facility Transitions, Personal Care and Homemaker Services, and Short-Term Post-Hospitalization Housing per provider update 26-991. All staff should reference current PA requirements when submitting requests to avoid claim denials, appeals, and grievances. Consult the Provider Library (Prior Authorizations > Imperial County – Community Health Plan of Imperial Valley or Provider Library > Medi-Cal > Prior Authorization Requirements) for complete code lists and submit complete and accurate PA requests following correct response time frames.