What insurance policy changes affect California providers?

This page tracks changes from major payers (including Medicaid managed care, commercial insurers, and Medicare Advantage plans) that explicitly apply to California. Changes include prior authorization updates, billing code additions or deletions, and reimbursement rate revisions.

How often are California policy changes updated?

Our scrapers run daily and publish new findings within 24 hours of detection. Each change includes an effective date where stated so you can prioritize what requires immediate action.

How do I get alerted to new California insurance policy changes?

Create a free alert on PolicyChanges.app and filter by state to California. You will get an email when new matching changes are detected: daily or weekly, your choice, on every plan.

PAYER POLICY CHANGES

California Insurance & Medicaid Policy Updates

California providers face a continuous stream of payer policy changes: coverage edits, prior authorization expansions, billing code revisions, and Medicaid reimbursement updates that affect day-to-day practice operations. This page surfaces every tracked policy change that explicitly names California, so your billing and compliance teams can act before the effective date, not after a claim denial.

Anthem BCBS · Effective Nov 15, 2026High impact
[California] Carelon Medical Benefits Management Clinical Appropriateness Guidelines updates
Effective for dates of service on and after November 15, 2026, updated Carelon Medical Benefits Management Clinical Appropriateness Guidelines apply to Medicare Advantage. Genetic and somatic tumor testing requires that all components of a test demonstrate clinical utility, and whole exome, whole genome and whole transcriptome analysis are considered not medically necessary. Joint procedures now require 12 weeks of conservative management with a shorter allowance for severe impact on daily activities, arthroscopy is excluded for Kellgren-Lawrence grade 4 osteoarthritis, and bilateral hypoglossal nerve stimulators are excluded for obstructive sleep apnea.
Health Net · Effective Nov 17, 2026High impact
26-1061sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk
Health Net California has updated the Injectable Medication HCPCS/DOFR (Division of Financial Responsibility) Crosswalk effective November 17, 2026, adding 11 new injectable medications, 15 new biosimilars, 6 new generic medications, and making 27 updates to existing codes with 3 DOFR categorization corrections. Billing teams must obtain and implement the complete crosswalk update (26-1061) to ensure accurate claims processing and proper financial responsibility assignments for injectable medications.
Health Net · Effective Nov 17, 2026High impact
26-1062sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk
Health Net/Community Health Plan of Imperial Valley updated the Injectable Medication HCPCS/DOFR Crosswalk effective November 17, 2026, adding 11 new injectable medications, 15 new biosimilars, 6 new generic medications, and making 27 updates to existing codes, plus 3 DOFR categorization corrections. Billing teams must obtain and implement the complete crosswalk update (26-1062) to ensure accurate coding and financial responsibility assignment for all injectable medication claims.
Health Net · Effective Nov 17, 2026High impact
26-1060sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk
Health Net's Pharmacy Advisory Committee has updated the Injectable Medication HCPCS/DOFR Crosswalk effective November 17, 2026, adding 11 new injectable medications, 15 new biosimilars, 6 new generic medications, and making 27 updates to existing codes. The update includes 3 DOFR categorization corrections, 2 administrative changes, and 21 code description updates that will affect how injectable medications are billed and assigned to financial responsibility categories under the Health Net Provider Participation Agreement.
Anthem BCBS · Effective Nov 30, 2026High impact
[California] Update: Unpaid Medicare cost share will be reported with CARC 303
Anthem Blue Cross will report unpaid Medicare cost share amounts using CARC 303 with Group Code CO on remittance advice for California Medicare Advantage claims finalized by November 30, 2026. Billing teams must verify QMB eligibility, avoid collecting these amounts from patients, and refund any incorrect patient payments, as balance-billing protections apply regardless of Medicaid payment status.
Anthem BCBS · Effective Dec 1, 2026High impact
[California] Include anatomical modifiers on outpatient facility claims
Effective December 1, 2026, Anthem Blue Cross will require anatomical modifiers (E1–E4, FA, F1–F9, TA, T1–T9, LC, LD, LM, RC, RI, LT, RT, or 50) on outpatient facility claims when the CPT or HCPCS code specifies identification of the anatomical site. Claims without the required modifier or with a mismatched modifier will not be eligible for reimbursement.
Anthem BCBS · Effective Dec 1, 2026High impact
[California] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem Blue Cross Medi-Cal is implementing a new combined reimbursement policy for laboratory modifiers 90 and 91 effective December 1, 2026. Modifier 90 (pass-through lab billing) will no longer be reimbursed except in specific circumstances (outside lab services billed by another provider using HCPCS S3620 or CPT 81528, or pathology services). Modifier 91 (repeat lab tests) remains eligible for reimbursement at 100% of fee schedule. The existing modifier 91 policy (G-06020) will be retired and consolidated into the new policy (G-20001).
Anthem BCBS · Effective Dec 1, 2026High impact
[California] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem Blue Cross is implementing a new combined reimbursement policy for laboratory service modifiers 90 and 91, effective December 1, 2026. Modifier 90 (pass-through laboratory billing) is now NON-REIMBURSABLE for professional and outpatient facility providers—the performing provider must bill directly for 100% reimbursement. Modifier 91 (repeat clinical diagnostic lab tests) remains eligible for reimbursement at 100% on professional claims. The existing modifier 91 policy (G-06020) will be retired.
Anthem BCBS · Effective Dec 1, 2026High impact
[California] Blood Product Administration services will no longer be billed separately
Effective December 1, 2026, Anthem Blue Cross Medi-Cal will no longer allow separate billing for Blood Product Administration services in Emergency Room, Clinic, and Treatment/Observation Room encounters. These services must now be included in the facility encounter reimbursement rather than billed as standalone line items. No change to benefits or covered services—only billing practice requirements are affected.
Anthem BCBS · Effective Dec 1, 2026High impact
[California] Prepare now for treatment room reimbursement updates
Effective December 1, 2026, Anthem Blue Cross Medi-Cal will no longer reimburse treatment room services (revenue codes 0760, 0761, 0769) as separate line items. These services must now be bundled and reimbursed as part of the main outpatient visit. Billing teams must review and update outpatient billing practices immediately to avoid claim denials and ensure compliant billing by the effective date.
Anthem BCBS · Effective Dec 1, 2026High impact
[California] Precertification/prior authorization requirement changes
Effective December 1, 2026, Anthem Blue Cross Medicare Advantage plans in California are adding prior authorization requirements for 30 specific procedure and supply codes, including prostate cancer screening (0591U), skin graft procedures (1044T-1049T, G0682, G0684), esophageal procedures (43192, 43201, 43210, 43236, 43497), neurolytic injections (64624), wound care matrices, neurostimulator generators, and orthotic devices. Claims submitted without prior authorization for these codes may be denied as ineligible for payment.
Anthem BCBS · Effective Dec 1, 2026High impact
[California] Precertification/prior authorization requirement changes
Effective December 1, 2026, Anthem Blue Cross Medicare Advantage (ISNP and CSNP plans) in California is adding 32 new codes to their prior authorization requirement list, spanning oncology testing, advanced skin grafting procedures, esophageal/gastric interventions, pain management, wound care products, and orthotic devices. All claims for these services submitted without prior authorization will be deemed ineligible for payment.
Anthem BCBS · Effective Dec 18, 2026High impact
[California] Medical Policies and Clinical Utilization Management Guidelines update
Anthem Blue Cross Medi-Cal has updated 23 medical policies and clinical utilization management guidelines effective December 18, 2026, affecting prior authorization requirements, coverage criteria, and medical necessity determinations for procedures ranging from cardiac interventions to diabetic devices. Several policies have changed from "investigational" or "revised" status, potentially affecting coverage for services previously considered medically necessary. The billing team must review each guideline to identify which procedures now require prior authorization or have new documentation requirements.
Medi-Cal · Effective Dec 31, 2026High impact
New Medi-Cal Providers Web Page: Medi-Cal Managed Care to Fee-for-Service Transition
Medi-Cal members with Unsatisfactory Immigration Status (UIS) will transition from managed care to fee-for-service coverage effective December 31, 2026. Providers currently enrolled only in Medi-Cal managed care must enroll in fee-for-service billing and update their systems to handle Treatment Authorization Requests (TARs) and fee-for-service billing requirements, or they will lose the ability to serve these members.
Medi-Cal · Effective Jan 1, 2027High impact
FQHC and RHC Policy for UIS Members Transitioning to Fee-for-Service on January 1, 2027
Effective January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status move from Medi-Cal managed care plans to Medi-Cal fee-for-service, so FQHC and RHC claims for these members must go directly to the Medi-Cal fiscal intermediary rather than to the former plan. Effective for services on or after January 1, 2027, claims sent to the former plan or to the FI for an MCP differential (wrap) rate will be denied, and from July 1, 2027, emergency and pregnancy-related services for these members are reimbursed only at the PPS rate with the appropriate diagnosis code and emergency indicator.
Health Net · Effective Jan 1, 2027High impact
26-1291 2027 Medicare Advantage and Special Needs Plan Updates: What You Need to Know
Effective January 1, 2027, Wellcare By Health Net is restructuring Medicare Advantage, D-SNP, and C-SNP plans across California counties, including plan name changes, plan segmentation, one plan termination, a new dental vendor (Liberty Dental Plan), and expansion of SSBCI benefits to D-SNP members. The practice must verify member plan assignments and benefits before rendering services, update charge entry to reflect accurate diagnosis codes for SSBCI eligibility, confirm dental network participation with the new vendor, and respond promptly to member attestation requests for C-SNP enrollment.
Molina Healthcare · Effective Jan 1, 2027High impact
10-30-2026 Reminder: Important information impacting claims payment for urgent care centers
Molina Healthcare of California requires all urgent care centers to submit a roster of rendering providers Previously due October 30, 2026 (date passed; verify current applicability) (a past deadline as of the analysis date). Starting January 1, 2027, claims must document the individual rendering provider instead of billing at the facility level only. Nurse Practitioners must include a supervising physician on the claim.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] 2027 Medicare formulary changes: Prepare now for
Effective January 1, 2027, Anthem Blue Cross Medicare Advantage plans in California will move 10 brand-name medications to nonformulary status, including common drugs for diabetes, asthma, COPD, anticoagulation, and inflammatory conditions. The practice must proactively review Medicare patients on these medications, coordinate transitions to covered alternatives before year-end, and submit prior authorizations electronically to avoid pharmacy claim denials and treatment delays in January.
Medi-Cal · Effective Jan 1, 2027High impact
ICF/DD-CNC Waiver Services Transition to LTC and a Reference Guide is Available
Effective January 1, 2027, ICF/DD-CNC waiver services are transitioning from outpatient billing guidelines to Long Term Care (LTC) billing guidelines. Two specific HCPCS code and modifier combinations (T2033 with modifiers U8 and U9) will no longer be reimbursable, and providers must transition to existing LTC policies and new ICF/DD-CNC billing code sets.
Molina Healthcare · Effective Jan 1, 2027High impact
10-27-2026 ECM, CICM, Community Supports, CCM, TCS and CHW services for Members transitioning to Medi-Cal Fee-for-Service
Effective January 1, 2027, Medi-Cal managed care plan members with unsatisfactory immigration status will transition to the Medi-Cal Fee-for-Service delivery system. ECM, CICM, Community Supports, CCM and TCS services will no longer be covered for transitioned members in Medi-Cal FFS, while CHW services will continue to remain available after January 1, 2027. Managed care plans must continue authorizing, providing and paying for these services through December 31, 2026.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] TCS care providers: UIS member transition to Medi-Cal FFS
Effective January 1, 2027, members with unsatisfactory immigration status (UIS) will transition from Anthem Blue Cross Medi-Cal Managed Care to Medi-Cal Fee-for-Service (FFS). Transitional Care Services (TCS) will no longer be available to these members under FFS, though TCS authorization continues through December 31, 2026. TCS care providers must complete transition planning and warm handoffs by December 31, 2026, to prevent care disruptions.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] Continuing Community Health Worker services following the UIS transition
Effective January 1, 2027, members with unsatisfactory immigration status (UIS) will transition from Anthem Medi-Cal Managed Care to Medi-Cal Fee-for-Service (FFS). Community Health Worker (CHW) providers must complete care coordination and member transitions before the deadline, then enroll in Medi-Cal FFS to continue serving these members and bill DHCS directly for services after the transition.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] Important information regarding UIS transition to Medi-Cal Fee-for-Service
Effective January 1, 2027, members with unsatisfactory immigration status (UIS) will transition from Anthem Blue Cross Medi-Cal Managed Care to Medi-Cal Fee-for-Service (FFS). California Children's Services (CCS) providers must confirm their ability to serve affected members under FFS and coordinate care transitions before the effective date to prevent service disruptions.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] Important notice for PCPs serving UIS members transitioning to Medi-Cal FFS
Effective January 1, 2027, members with unsatisfactory immigration status (UIS) will transition from Anthem Medi-Cal Managed Care to Medi-Cal Fee-for-Service (FFS). PCPs who wish to continue treating these members must confirm enrollment in Medi-Cal FFS and billing capabilities. Referral authorization will continue through December 31, 2026, with DHCS preferring referrals for ongoing or post-transition services be directed to dual-enrolled Anthem Medi-Cal Managed Care/FFS providers.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] Action required: Coordinate Community Supports transitions for UIS members
Effective January 1, 2027, Medi-Cal members with unsatisfactory immigration status (UIS) will transition from Medi-Cal Managed Care to Medi-Cal Fee-for-Service (FFS). Community Supports services will no longer be available through Medi-Cal FFS for these members. Billing teams and care providers must coordinate transition planning and identify alternative services before the deadline to minimize disruptions.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] Transition of Enhanced Care Management UIS members to Medi-Cal Fee-for-Service
Effective January 1, 2027, Medi-Cal members with unsatisfactory immigration status (UIS) will transition from Anthem Blue Cross Medi-Cal Managed Care to Medi-Cal Fee-for-Service (FFS). Enhanced Care Management (ECM) services will no longer be available to these members under FFS; providers must complete transition planning, care coordination, and warm handoffs by December 31, 2026. Providers wishing to continue serving these members must enroll as Medi-Cal FFS providers and bill under FFS coverage policies.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] Help support accurate inpatient claims with the correct primary diagnosis
Effective January 1, 2027, Anthem Blue Cross will enforce stricter review of inpatient facility claims to ensure the primary diagnosis code reflects the actual primary reason for admission and complies with CMS coding guidelines. Claims submitted with unacceptable primary diagnosis codes will be denied and require corrected claim submission; no balance billing of members is permitted.
Molina Healthcare · Effective Jan 1, 2027High impact
10-16-2026 Important information impacting claims payment for urgent care centers
Molina Healthcare of California requires all urgent care centers to submit a roster of their providers by October 30, 2026, and quarterly thereafter. Effective January 1, 2027, urgent care centers must submit claims documenting the rendering provider instead of billing at the facility level. Nurse Practitioners must include a supervising physician on claims.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] California 2027 Medicare Advantage plan changes
Anthem Blue Cross is making significant changes to its California Medicare Advantage plan portfolio effective January 1, 2027, including service area reductions for two HMO plans, non-renewal of five HMO plans, introduction of one new PPO plan, transition of one existing PPO plan to a new plan ID, and non-renewal of two PPO plans. Billing teams must verify plan eligibility, member ID changes, and updated benefit information for affected members in Sacramento, Yolo, San Joaquin, Alameda, Santa Clara, Fresno, Kern, Kings, Madera, Merced, Monterey, San Diego, San Luis Obispo, Stanislaus, Tulare, Ventura, Butte, Napa, Shasta, Solano, Sonoma, Sutter, Tehama, Yuba, Alpine, Amador, Calaveras, El Dorado, Inyo, Mono, and Tuolumne counties.
L.A. Care Health Plan · Effective Jan 1, 2027High impact
Unsatisfactory Immigration Status (UIS) Member Transition to Full Scope Medi-Cal Fee-for-Service
Effective January 1, 2027, L.A. Care Health Plan members with unsatisfactory immigration status (UIS) will transition from L.A. Care managed care to California Medi-Cal Fee-for-Service (FFS). Providers must complete transition planning and care coordination by December 31, 2026, and enroll in Medi-Cal FFS by January 1, 2027 to continue serving these members. Enhanced Care Management, CICM, Community Supports, Complex Care Management, and Transitional Care Services will end for transitioned members, but Community Health Worker services will continue in Medi-Cal FFS.
Molina Healthcare · Effective Jan 1, 2027High impact
10-01-2026 Important information for CCS Paneled Providers: Transition of certain Medi-Cal Members from managed care to fee-for-service (FFS) effective January 1, 2027
Effective January 1, 2027, certain Medi-Cal members with Unsatisfactory Immigration Status (UIS) will transition from Molina Healthcare managed care to Medi-Cal Fee-for-Service (FFS). CCS-paneled providers must continue authorized services through December 31, 2026, then prepare to bill under FFS requirements if they participate in the FFS network. Providers should verify FFS participation status and engage in care coordination before the transition to minimize service disruptions.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] Review 2027 provider manual updates
Anthem Blue Cross is updating its California Medi-Cal Managed Care provider manual in January 2027 with operational and regulatory changes affecting behavioral health coordination, community supports, payment methods, credentialing standards, and encounter data requirements. Billing teams must review multiple sections including new prior authorization protocols for behavioral health treatments, revised payment method defaults, updated contact procedures, and compliance with new quality measure standards.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective for dates of service on or after January 1, 2027, the listed codes require precertification/prior authorization through Carelon Medical Benefits Management for Anthem Blue Cross Medicare Advantage Preferred Provider Organization (PPO) plans offered in California. The codes cover full-thickness skin harvest and autologous heterogeneous skin-construct grafts (1044T through 1049T), esophagoscopy and endoscopic procedures (43192, 43201, 43210, 43236, 43257, 43497), skin substitute products (A2036 through A2045, G0681 through G0684, Q4182 through Q4440) and neurostimulator generators (C1826, C1827). These services are being added to the review program to support consistent application of current clinical guidelines and evidence-based coverage criteria.
Medi-Cal · Effective Jan 1, 2027High impact
Medi-Cal Fee-for-Service Transition for UIS Members
Beginning January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status (UIS) will transition from managed care to fee-for-service Medi-Cal. Providers must enroll in Medi-Cal fee-for-service billing, update PAVE enrollment, and comply with fee-for-service billing requirements including Treatment Authorization Requests (TARs) to continue serving these members after December 31, 2026.
Molina Healthcare · Effective Jan 1, 2027High impact
09-01-2026 AMA updates global obstetric CPT code structure effective 01-01-27
Effective January 1, 2027, the AMA is replacing the current global obstetric CPT code structure with a disaggregated model that separately identifies antepartum care, labor management, delivery care, and postpartum services. California's Medi-Cal program intends to align with these changes pending CMS approval. Billing teams must prepare documentation and workflow changes to accommodate the new maternity care coding structure.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] Community Supports Short-Term Post-Hospitalization Housing service ending January 2027
Effective January 1, 2027, Anthem Blue Cross (Medi-Cal) will end the Community Supports Short-Term Post-Hospitalization Housing (STPHH) service. No new authorizations will be issued after December 1, 2026, and all existing authorizations expire December 31, 2026. Providers must identify affected members, continue services through authorized periods, and coordinate transition planning including connection to Housing Transition Navigation services, ECM care providers, and permanent housing resources.
Health Net · Effective Jan 1, 2027High impact
26-1008a Prepare for Unsatisfactory Immigration Status Member Transitions to Medi-Cal FFS
Effective January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status (UIS) will transition from managed care plans to Medi-Cal Fee-for-Service (FFS). Providers must be enrolled in Medi-Cal FFS by the deadline to continue treating these members and receive reimbursement. Billing processes, claims submission, and authorization requirements will shift from managed care to FFS workflows.
L.A. Care Health Plan · Effective Jan 1, 2027High impact
Unsatisfactory Immigration Status (UIS) Member Transition
Effective January 1, 2027, L.A. Care Health Plan members with Unsatisfactory Immigration Status (UIS) will transition from Medi-Cal managed care to Medi-Cal Fee-for-Service (FFS). Providers must be enrolled in Medi-Cal FFS through PAVE by January 1, 2027 to continue serving these patients and receive reimbursement. Billing workflows must shift from managed care to FFS processes, and providers should familiarize themselves with FFS billing requirements, rates, and newly available care management billing codes.
Health Net · Effective Jan 1, 2027High impact
26-1008 Prepare for Unsatisfactory Immigration Status Member Transitions to Medi-Cal FFS
Effective January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status (UIS) will transition from managed care to Medi-Cal Fee-for-Service (FFS). Providers must enroll in Medi-Cal FFS through the PAVE system by the deadline to continue treating these members and receive reimbursement. All claims and authorization processes for UIS members will shift from managed care plans to Medi-Cal FFS processing.
Health Net · Effective Jan 1, 2027High impact
26-1009 Prepare for Unsatisfactory Immigration Status Member Transitions to Medi-Cal FFS
Effective January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status (UIS) will transition from managed care to Medi-Cal Fee-for-Service (FFS). Providers must be enrolled in Medi-Cal FFS by this date to continue treating these members and receive reimbursement. All billing, claims, and authorization processes will shift from managed care plans to Medi-Cal FFS requirements.
Health Net · Effective Jan 1, 2027High impact
26-1010 Prepare for Unsatisfactory Immigration Status Member Transitions to Medi-Cal FFS
Effective January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status (UIS) will transition from managed care to Medi-Cal Fee-for-Service (FFS). Providers must enroll in Medi-Cal FFS through the PAVE system by this date to continue treating affected UIS members and receive reimbursement. All billing, claims submission, and prior authorization processes will shift from managed care plans to Medi-Cal FFS starting January 1, 2027.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] Medi-Cal Managed Care fee-for-service transition for members with unsatisfactory immigration status
Effective January 1, 2027, Anthem Medi-Cal Managed Care members with unsatisfactory immigration status (UIS) will transition to Medi-Cal fee-for-service (FFS) delivery. Providers must be enrolled in Medi-Cal FFS through PAVE by January 1, 2027, to continue serving these members and receive reimbursement. Billing workflows must shift from managed care to FFS processes, including Treatment Authorization Requests (TARs) and FFS-specific billing codes.
Health Net · Effective Jan 1, 2027High impact
26-989 Changes to Community Supports Services, Effective January 1, 2027
Effective January 1, 2027, Health Net will discontinue three Community Supports services: Assisted Living Facility Transitions, Personal Care and Homemaker Services, and Short-Term Post-Hospitalization Housing. Providers must identify affected members, continue services through December 31, 2026, and coordinate care transitions. This impacts Medi-Cal in 10 California counties.
Health Net · Effective Jan 1, 2027High impact
26-991 Changes to Community Supports Services, Effective January 1, 2027
Effective January 1, 2027, Community Health Plan of Imperial Valley is terminating three Community Supports services: Assisted Living Facility Transitions, Personal Care and Homemaker Services, and Short-Term Post-Hospitalization Housing. The billing team must identify all affected members currently receiving these services, ensure services end by December 31, 2026, and coordinate care transitions to avoid service gaps.
Health Net · Effective Jan 1, 2027High impact
26-990 Changes to Community Supports Services, Effective January 1, 2027
CalViva Health is discontinuing three Community Supports services effective January 1, 2027: Assisted Living Facility Transitions, Personal Care and Homemaker Services, and Short-Term Post-Hospitalization Housing. Billing teams must identify affected members, ensure services end by December 31, 2026, and coordinate transition planning to avoid service gaps and claim denials.
Molina Healthcare · Effective Jan 1, 2027High impact
07-29-2026 DHCS policy guide for transition of the unsatisfactory immigration status population from managed care to Medi-Cal fee-for-service – Version 1.0 IE LA SAC SD
Effective January 1, 2027, Medi-Cal members with unsatisfactory immigration status (UIS) will transition from managed care plans to Medi-Cal Fee-for-Service (FFS). Providers must enroll in Medi-Cal FFS through DHCS to continue serving these patients and receive reimbursement. Billing workflows, care coordination processes, and prior authorization procedures will shift from managed care to FFS requirements.
Medi-Cal · Effective Jan 1, 2027High impact
AMA to Update Global Obstetric CPT Code Structure
Effective January 1, 2027, the AMA is replacing the current global obstetric CPT code structure with a disaggregated framework that separately bills antepartum care, labor management, delivery care, and postpartum services. Medi-Cal will align with these changes subject to CMS approval, requiring billing teams to transition from bundled maternity codes to individual service-specific codes.
Medi-Cal · Effective Feb 1, 2027High impact
Ordering, Referring and Prescribing: NPI Requirements for DME and Clinical Laboratory Providers
Effective February 1, 2027, DME and Clinical Laboratory providers billing Medi-Cal must include a valid 10-digit Individual (Type 1) Ordering provider NPI on applicable claims. The Ordering NPI must be actively enrolled as a participating Medi-Cal provider by May 1, 2027. Claims will be denied if the Ordering provider NPI is missing, invalid, inactive, not on NPPES, or is a group NPI. Specific HCPCS codes with replacement modifiers are exempt from this requirement.
Medi-Cal · Effective Feb 1, 2027High impact
Ordering, Referring and Prescribing: NPI Requirements for LTC Providers
Effective February 1, 2027, Long Term Care (LTC) providers billing Medi-Cal must include both valid Attending and Referring provider NPIs (Type 1 Individual) on all claim forms, including UB-04. An Attending NPI is mandatory on all claims; both NPIs are required on initial, discharge, and transfer claims. Claims will be denied if NPIs are invalid, missing, inactive, or not Type 1 Individual NPIs on the NPPES file for the date of service billed.
Health Net · Effective Nov 15, 2026Medium impact
26-1317 Transition to InterQual Clinical Review Criteria
Effective November 15, 2026, Wellcare By Health Net will evaluate behavioral health authorization and continued-stay medical necessity reviews using InterQual clinical criteria instead of LOCUS/CALOCUS scoring. Existing authorization submission processes and forms remain the same, so the practice must still submit the clinical information required for review.

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[California] Carelon Medical Benefits Management Clinical Appropriateness Guidelines updates

26-1061sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk

26-1062sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk

26-1060sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk

[California] Update: Unpaid Medicare cost share will be reported with CARC 303

[California] Include anatomical modifiers on outpatient facility claims

[California] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[California] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[California] Blood Product Administration services will no longer be billed separately

[California] Prepare now for treatment room reimbursement updates

[California] Precertification/prior authorization requirement changes

[California] Precertification/prior authorization requirement changes

[California] Medical Policies and Clinical Utilization Management Guidelines update

New Medi-Cal Providers Web Page: Medi-Cal Managed Care to Fee-for-Service Transition

FQHC and RHC Policy for UIS Members Transitioning to Fee-for-Service on January 1, 2027

26-1291 2027 Medicare Advantage and Special Needs Plan Updates: What You Need to Know

10-30-2026 Reminder: Important information impacting claims payment for urgent care centers

[California] 2027 Medicare formulary changes: Prepare now for

ICF/DD-CNC Waiver Services Transition to LTC and a Reference Guide is Available

10-27-2026 ECM, CICM, Community Supports, CCM, TCS and CHW services for Members transitioning to Medi-Cal Fee-for-Service

[California] TCS care providers: UIS member transition to Medi-Cal FFS

[California] Continuing Community Health Worker services following the UIS transition

[California] Important information regarding UIS transition to Medi-Cal Fee-for-Service

[California] Important notice for PCPs serving UIS members transitioning to Medi-Cal FFS

[California] Action required: Coordinate Community Supports transitions for UIS members

[California] Transition of Enhanced Care Management UIS members to Medi-Cal Fee-for-Service

[California] Help support accurate inpatient claims with the correct primary diagnosis

10-16-2026 Important information impacting claims payment for urgent care centers

[California] California 2027 Medicare Advantage plan changes

Unsatisfactory Immigration Status (UIS) Member Transition to Full Scope Medi-Cal Fee-for-Service

10-01-2026 Important information for CCS Paneled Providers: Transition of certain Medi-Cal Members from managed care to fee-for-service (FFS) effective January 1, 2027

[California] Review 2027 provider manual updates

[California] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

Medi-Cal Fee-for-Service Transition for UIS Members

09-01-2026 AMA updates global obstetric CPT code structure effective 01-01-27

[California] Community Supports Short-Term Post-Hospitalization Housing service ending January 2027

26-1008a Prepare for Unsatisfactory Immigration Status Member Transitions to Medi-Cal FFS

Unsatisfactory Immigration Status (UIS) Member Transition

26-1008 Prepare for Unsatisfactory Immigration Status Member Transitions to Medi-Cal FFS

26-1009 Prepare for Unsatisfactory Immigration Status Member Transitions to Medi-Cal FFS

26-1010 Prepare for Unsatisfactory Immigration Status Member Transitions to Medi-Cal FFS

[California] Medi-Cal Managed Care fee-for-service transition for members with unsatisfactory immigration status

26-989 Changes to Community Supports Services, Effective January 1, 2027

26-991 Changes to Community Supports Services, Effective January 1, 2027

26-990 Changes to Community Supports Services, Effective January 1, 2027

07-29-2026 DHCS policy guide for transition of the unsatisfactory immigration status population from managed care to Medi-Cal fee-for-service – Version 1.0 IE LA SAC SD

AMA to Update Global Obstetric CPT Code Structure

Ordering, Referring and Prescribing: NPI Requirements for DME and Clinical Laboratory Providers

Ordering, Referring and Prescribing: NPI Requirements for LTC Providers

26-1317 Transition to InterQual Clinical Review Criteria