26-642 Submit Medi‑Cal Rx and Fee‑for‑Service Carved‑Out Medication Claims Correctly

Date: 05/21/26

Effective July 27, 2026: Do not bill Health Net for carved‑out medications

Certain medications are carved out of Medi‑Cal Managed Care and must be billed to Medi‑Cal Rx or Medi‑Cal Fee‑for‑Service (FFS), not to Health Net.

Although carve‑out requirements are already in place, effective July 27, 2026, Health Net will begin enforcing claim denials for all applicable carved‑out medications, including additional codes identified through recent review, in accordance with California Department of Health Care services (DHCS) guidance.

Why this guidance matters

We have identified cases where carved-out medication claims were submitted to Health Net instead of the correct Medi-Cal payer. When claims are submitted to the wrong payer, they may be denied or delayed.

Submitting claims to the correct payer helps avoid denials and rework.

How to bill carved‑out medication claims

Bill carved‑out medications based on the type of claim:

• Pharmacy claims
  • Bill medications that are part of the pharmacy carve‑out to Medi‑Cal Rx.
  • Medi-Cal Rx manages the pharmacy benefit under Medi-Cal FFS.
• Medical or institutional claims
  • Bill carved out medications on medical or institutional claims to Medi‑Cal FFS.

Do not bill Health Net for carved‑out medications.

What happens if claims are billed incorrectly

Claims for carved-out medications that are sent to Health Net may be denied. Providers will be directed to resubmit the claim to the appropriate Medi‑Cal payer.

Resources

Use these DHCS resources to confirm which medications are carved out and where to submit claims:

• Medi‑Cal Rx Overview and Provider Resources
  
• Medi‑Cal Rx Frequently Asked Questions
  
• Medi‑Cal Rx Pharmacy Carve‑Out Scope Document (PDF)
  
• Medi‑Cal Provider Manuals – Fee‑For‑Service Billing Guidance
  

Need help? Contact us

If you have questions regarding the information contained in this update, contact CalViva Health at
888-893-1569. Behavioral Health providers can call 844-966-0298.
 

This information applies to Physicians, Practitioners, 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.