26-825 Follow New Maternity Care Requirements to Avoid Claim Delays

Date: 07/02/26

Complete required screenings, document opt-outs and follow updated care protocols now in effect

Medi-Cal maternity care requirements are now in effect and require immediate provider action.

Key responsibilities include:

• Complete required screenings and risk assessments.
• Document patient decisions, including screening opt-outs.
• Provide required patient education.

These actions are required to avoid claim processing delays and ensure timely care.

Required action from physicians, practitioners and other providers

To remain compliant, complete the following:

• Screening and risk assessment
  • Conduct risk assessments at:
    • Initial visit
    • Each trimester
    • Postpartum
  • Perform and document required screenings (e.g. depression, intimate partner violence).
• Prenatal screening education
  • Inform pregnant members about the California Prenatal Screening (PNS) Program before 21 weeks.
  • Explain that participation is voluntary.
• Documentation and claims requirements
  • For patients who opt out of the PNS Program:
    • Document the patient’s opt-out decision.
    • Include opt-out status on claims, when applicable, to prevent processing delays.
    • Follow-up care is not coordinated through the PNS Program.
  • When screening occurs outside of the PNS Program:
    • Document results and clinical decisions.
• Newborn screening
  • Complete newborn screening within 12–48 hours after birth.
  • Coordinate follow-up care as needed.
• Care coordination and referrals
  • Offer or refer to:
    • Behavioral health care.
    • Lactation services and supplies.
    • Doula and Community Health Worker services.
  • Refer high-risk patients to appropriate specialists.

Key program changes

1 Faster access to care

• Prior authorization is required for basic prenatal, maternal and preventive services.
• Authorizations timelines:
  • Standard: within 5 business days, not to exceed 7 calendar days.
  • Urgent: within 72 hours.

2 Expanded support services

• Patients have access to:
  • Doula services.
  • Lactation support.
  • Behavioral health services.
  • Community-based services.

3 Updated requirements

• Screening, documentation and member education requirements have been updated.
• Additional documentation applies when screening occurs outside of the NS Program.

Effective dates for new requirements

• January 1, 2026: Requirements are in effect and should be incorporated into current workflows.
• July 1, 2026: Additional care coordination requirements begin, including Transitional Care Services for pregnancy, postpartum and post-discharge care.

Review and update workflows now to ensure continued compliance as additional requirements take effect.

Access the full policy guidance

For complete program requirements, refer to the Department of Health Care Servies All Plan Letter 26-005 (PDF).

Need help? Contact us

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

This information applies to Physicians and 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.