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25-1147m Support Member Needs With New CBAS and LTC Forms

Date: 12/05/25

Use the updated forms today to help members get care faster

Health Net, on behalf of CalViva Health, has updated two forms to help physicians and other providers request services more efficiently for members:

  • Community-Based Adult Services (CBAS) Treatment Request Form
  • Long-Term Care (LTC) Authorization Notification Form

These updates are designed to reduce confusion, improve accuracy and support faster access to care.

CBAS Treatment Request Form

Physicians and other providers who believe a member may benefit from the CBAS program must request a face-to-face assessment. This request can be sent through the Health Net provider portal or by submitting the CBAS Treatment Request Form.

How to complete and submit the form:

  • Access the form in the Medi-Cal Provider Library > Forms and References.
  • Fax the completed form and any attachments to 833-581-5908.
  • If the fax has private health information, add a cover sheet that says, “PROTECTED HEALTH INFORMATION.”

LTC Authorization Notification Form

Health Net has removed Nursing Facility Level A and B from the LTC Authorization Notification Form. These terms caused confusion, especially in reviews by the Department of Managed Health Care. Removing these terms make the form clearer and easier to use.

  • Level A: For intermediate care facility (ICF) members. These providers do not use this form, so Level A was removed.
  • Level B: Although Level B refers to custodial care, the Plan will now use Nursing Facility Residential LOC 2 to indicate long-term custodial care, as reflected in TruCare.

 

How to complete and submit the form:

  • Access the form in the Medi-Cal Provider Library > Forms and References.
  • Fax the completed form and any attachments to 855-851-4563.

Additional information

Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on the provider portal.

Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

 

If you have questions regarding the information contained in this update, contact CalViva Health at
888-893-1569.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.



Last Updated: 12/03/2025