---
title: Health Net Community Solutions ABA coverage (Medi-Cal, incl. CalViva Health).
url: "https://carelu.com/payers/health-net-community-solutions-california"
markdown_url: "https://carelu.com/payers/health-net-community-solutions-california.md"
state: CA (California)
payer: Health Net Community Solutions (Medi-Cal) / CalViva Health
kind: Medicaid managed care plan (MCO)
parent_program: Medi-Cal (California Medicaid)
description: "How Health Net Community Solutions and CalViva Health cover Medi-Cal Behavioral Health Treatment (ABA) — policy CA.CP.BH.104 (April 2026), the 6-hour/30-hour intensity threshold, 12-month diagnostic evaluation and 2-month assessment clocks, 10% protocol-modification floor, the no-addendum rule, telehealth limits and ABA@healthnet.com submission."
last_reviewed: September 2026
---

# Health Net Community Solutions ABA coverage (Medi-Cal, incl. CalViva Health).

_Payer Guide · Health Net Medi-Cal · Last updated September 2026 · 10 primary sources_

> Health Net + CalViva Medi-Cal; new policy CA.CP.BH.104 (4/20/2026): 6 h/day–30 h/wk cap, 12-month dx eval, 6-month auths.

Health Net Community Solutions is the commercial-plan side of the Two-Plan model in Los Angeles (1.07 million members) and several Central Valley counties, one of the Sacramento GMC plans, and a Regional-model plan — about 1.43 million Medi-Cal members in August 2026. It also administers CalViva Health, the local initiative for Fresno, Kings and Madera (406,000 members), which "contracts with Health Net Community Solutions, Inc. to provide and arrange for network services." For both, BHT goes to Health Net’s in-house Behavioral Health Autism Center, and since April 20, 2026 its medical-necessity criteria are Health Net’s own Medi-Cal policy CA.CP.BH.104, which replaced the CASP criteria.

This plan administers the **Medi-Cal (California Medicaid)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Medi-Cal (California Medicaid) guide](https://carelu.com/payers/medi-cal-california-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — ABA is "Authorized by the Behavioral Health Team" on the Medi-Cal PA list, and the PA form lists H0031 or 97151/97152/0362T by hours per authorization period; CA.CP.BH.104 treats the behavioral assessment as its own request [4][6][1]
- **Prior auth for treatment**: Required — PA form plus an updated treatment plan before services; initiation needs a behavioral assessment within two months, a diagnostic evaluation within 12 months and a plan "valid for six months"; addendums are no longer accepted (a change needs a new full request, and the old auth is ended) [1][5]
- **Autism diagnosis required?**: No autism diagnosis — a physician or licensed clinical psychologist recommendation "regardless of diagnosis" — but initiation requires a diagnostic evaluation with a current DSM diagnosis within 12 months, so some diagnosis is expected [1]

## At a glance

- **Plan type:** Medi-Cal commercial plan (Two-Plan counties incl. Los Angeles), GMC Sacramento, Regional counties; administers CalViva Health
- **Criteria:** CA.CP.BH.104 (eff. 4/20/2026) + documentation policy CA.CP.BH.105
- **Diagnosis:** Not ASD-specific — recommendation "regardless of diagnosis"; diagnostic evaluation within 12 months
- **Intensity threshold:** 6 hours/day, 30 hours/week unless documentation justifies more
- **Supervision floor:** Protocol modification ≥ 2 h/week or 10% of direct hours (≤ 20% unless justified)
- **Reauthorization:** Every 6 months; attendance under 80% needs justification
- **Submit via:** ABA@healthnet.com or fax 855-427-4798; BH Provider Services 844-966-0298

## Health Net’s Medi-Cal ABA criteria (April 2026)

CA.CP.BH.104 applies APL 23-010 with Health Net’s own clocks. The recommendation comes from "A licensed physician or licensed clinical psychologist … regardless of diagnosis" (Health Net’s referral form is "encouraged"); where there is no diagnosis or a non-autism diagnosis, "the recommendation/referral form must be less than one year old." Initiation needs a behavioral assessment "completed no more than two months prior to the start of the initial treatment authorization, by the current rendering provider," a diagnostic interview or evaluation "within 12 months of the authorization request" (DSM diagnosis, mental status, history, risk), and a treatment plan "valid for six months" with crisis, school-based, titration and transition plans. Treatment hours should "not exceed six hours per day up to a total of 30 hours per week" unless "clinical documentation justifies additional hours," and "The number of medically necessary BHT hours may not be reduced based on time spent in school." Protocol modification must be "at least two hours per week or 10% of the direct service hours provided, whichever is greater." Reauthorization is every six months; "If attendance falls below 80% of the authorized hours," supporting documentation is required. [1][3][5][8][7]

Mechanics: send the ABA PA form (24-992 for Health Net, 24-990 for CalViva) and treatment plan to the Behavioral Health Autism Center at ABA@healthnet.com or fax 855-427-4798. "Addendums to existing authorizations can no longer be accommodated" — for a change, submit a new full request (start date = when the change is needed, end date = current auth end) with a clinical-rationale letter, and "the existing authorization will be ended." Families without a provider can be contacted by an Autism Center utilization review clinician, or call Behavioral Health at 888-935-5966 for in-network providers. [1][3][5][8][7]

## Intake gates

The questions that decide whether a family can start with Health Net Community Solutions (Medi-Cal) / CalViva Health, and what they have to bring.

- **Age limit**: "Member/enrollee is < 21 years old and medically stable" (CA.CP.BH.104). No minimum age. [1]
- **Diagnosis recency**: Two clocks: with no diagnosis or a non-autism diagnosis, "the recommendation/referral form must be less than one year old," and the diagnostic interview/evaluation must be "within 12 months of the authorization request." The behavioral assessment must be no more than two months before the initial authorization, and updated assessments are due "at least every six months." [1]
- **Who may diagnose**: The recommendation comes from a physician (MD/DO) or licensed clinical psychologist (PsyD/PhD) — Health Net’s referral form "must be completed by a physician or licensed psychologist." The policy does not separately specify who writes the diagnostic evaluation. [1][8]
- **Diagnostic tools required**: No instrument is mandated for the diagnosis. The treatment assessment must include direct observation and at least one of an FBA (descriptive FBA, traditional FA, IISCA) or a skills assessment (VB-MAPP, ABLLS-R, AFLS, PEAK, EFL, SSIS, Socially Savvy, other); "If the Vineland … or … ABAS is used as a skills assessment, an additional, direct skills assessment is required." [1]
- **Referral required?**: The physician or psychologist completes the ABA referral form and gives it "to the parent/caregiver or their chosen in-network ABA provider," or sends it to ABA@healthnet.com / fax 855-427-4798; no PCP or medical-group referral is needed — members "do not need to contact their primary care physician (PCP), participating physician group (PPG)… to request a referral for mental health care services." [8][11]
- **Telehealth**: Allowed under the DHCS telehealth rules, but CA.CP.BH.105 limits the required monthly protocol-modification contact (97155/H0032): "Synchronous audio/visual telehealth services are permissible only when the member/enrollee has a documented access barrier (e.g., geographic limitations, provider shortages, or documented parent/caregiver hardship)," with the modality, rationale and an unobstructed real-time view documented and rendering staff’s "camera turned on." CA.CP.BH.104 treats telehealth as a supplement "to the traditional in person service delivery model." [2][1]
- **Other insurance (who pays first)**: "Medi-Cal is always the payer of last resort, including Medicare and TRICARE." Bill the primary first, then Health Net with the EOB within 180 days, with proof of exhaustion (denial or EOB showing non-coverage); payment is capped at Medi-Cal limits less the other payment. On authorization: "Where a benefit is not covered by the member’s primary insurance and the service is covered and requires authorization by Health Net Medi-Cal, an out-of-network provider may leverage a letter of agreement (LOA)" — so Health Net’s authorization applies when the primary does not cover ABA. Whether it is required when the primary does cover ABA is not stated. [9]
- **Prior-auth decision time** _(plan-dependent)_: Health Net publishes no number; it "has adopted the timeliness standards approved by the Industry Collaboration Effort (ICE) and … NCQA." The state rule sets the ceiling for Medi-Cal plans: APL 21-011 — standard decisions within five business days of receiving the information reasonably necessary, never more than 14 calendar days, 72 hours expedited — and, from January 1, 2026, 42 CFR 438.210(d) caps standard decisions at 7 calendar days. Reauthorization every six months. [12][13][14]
  - Blocked on: The ICE "Medi-Cal UM Timeliness Standards" (iceforhealth.org), or Health Net BH Provider Services 844-966-0298.

## Delivery and billing rules

Coverage decides whether Health Net Community Solutions (Medi-Cal) / CalViva Health pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Protocol modification (97155/H0032/0373T) must be "at least two hours per week or 10% of the direct service hours provided, whichever is greater" (one to two hours a week is acceptable under 10 direct hours), and "no more than 20% of direct service hours provided (unless clinical documentation justifies)"; at least monthly one-on-one protocol development with the member; consistently falling below 10% "will trigger an individualized clinical documentation review." Parent training "ideally for a minimum of two hours per month"; parent participation "encouraged but not required." [1][2]
- **Daily limits / MUEs**: Treatment hours should "not exceed six hours per day up to a total of 30 hours per week" unless "clinical documentation justifies additional hours" (high-intensity behaviors or significant deficits) — a documentation threshold rather than a hard cap, since APL 23-010 prohibits hour caps. Hours may not be reduced for school time; MUEs follow the ABA Coding Coalition/CMS. [1][2]
- **Session-note signature**: Service notes are completed "prior to claim submission," with the organization name, member name on each page, DOB, exact start and end time, pauses, location, code, "Signature and credential of qualified rendering provider/technician," and a clinical summary; late notes carry the creation date and an explanation. Treatment plans need a "HIPAA compliant signature, credentials, and role" — "Parent/guardian signature is preferred but not required." [2][1]
- **Place of service**: The plan must justify each setting — "home, school (onsite or remote), or community-based settings" — and school services need a detailed school-based plan (rationale, schedule, IEP justification, titration, LEA coordination). Services "in lieu of school (member/enrollees age six or older)" are a ground for discontinuation. [1]
- **Bill as provider**: The PA form captures the group name and TIN and the case supervisor’s NPI. Rendering tiers: QAS provider (BCBA), QAS professional (associate behavior analyst, BMA, psychological associate, AMFT, ACSW, APCC under supervision) and QAS paraprofessional. Health Net publishes no statement on PAVE enrollment. [6][1]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: No explicit same-clock-time rule. CA.CP.BH.105 says "97155 may be used to demonstrate new or modified protocol to a technician with the member/enrollee present," and "Technician supervision only or team meetings do not constitute protocol modification"; it defers MUEs to the ABA Coding Coalition and CMS. [2]
  - Ask the plan: Health Net BH Provider Services 844-966-0298 or its claims payment policy — whether 97153 and 97155 may be billed for the same minutes.

## What intake should collect for Health Net Community Solutions (Medi-Cal) / CalViva Health

- **Recommendation under a year old:** From an MD/DO or licensed clinical psychologist — must be less than one year old when there is no autism diagnosis.
- **Diagnostic evaluation within 12 months:** DSM diagnosis, mental status and history — required for initiation.
- **Fresh behavioral assessment:** Completed within two months of the requested start by the provider who will treat.
- **Planned hours and school schedule:** Over 6 h/day or 30 h/week needs documentation; school hours cannot reduce BHT, but services "in lieu of school" for age 6+ are a discontinuation ground.
- **Other coverage:** Primary insurance billed first; if it does not cover ABA, Health Net’s authorization applies.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does Health Net Medi-Cal (and CalViva) cover ABA?

Yes — Behavioral Health Treatment for members under 21 on a physician or licensed clinical psychologist recommendation, regardless of diagnosis, reviewed by Health Net’s Behavioral Health Autism Center under policy CA.CP.BH.104.

### Is there an hour cap on Health Net Medi-Cal ABA?

Not a hard cap. CA.CP.BH.104 expects no more than 6 hours a day and 30 hours a week unless clinical documentation justifies more, and hours cannot be reduced for school time.

### How do I change hours on a Health Net ABA authorization?

Submit a new complete PA request with a letter explaining the clinical reason — addendums are no longer accepted, and the existing authorization is ended.

## Primary sources

1. [Health Net CA.CP.BH.104 — Applied Behavior Analysis (Medi-Cal), eff. 4/20/2026](https://www.healthnet.com/content/dam/centene/healthnet/pdfs/general/ca/policies/CA.CP.BH.104.pdf)
2. [Health Net CA.CP.BH.105 — ABA Documentation Requirements (rev. 7/2026)](https://www.healthnet.com/content/dam/centene/healthnet/pdfs/general/ca/policies/CA.CP.BH.105.pdf)
3. [Health Net provider notice 26-196 — Updated ABA Medical Necessity Criteria for Medi-Cal](https://providerlibrary.healthnetcalifornia.com/news/26-196-updated-aba-medical-necessity-criteria-for-medi-cal--effe.html)
4. [Health Net — Prior Authorization Requirements, California Medi-Cal (eff. 7/9/2026)](https://providerlibrary.healthnetcalifornia.com/medi-cal/prior-authorization-requirements---medi-cal.html)
5. [Health Net Medi-Cal Provider Manual — Autism Spectrum Disorders (updated 4/30/2026)](https://providerlibrary.healthnetcalifornia.com/medi-cal/provider-manual/benefits/autism-spectrum-disorders-medi-cal.html)
6. [Health Net — ABA Prior Authorization Request Form (24-992)](https://providerlibrary.healthnetcalifornia.com/content/dam/centene/healthnet/pdfs/providerlibrary/500234-ABA-Prior-Auth-Request-Form-MCL.pdf)
7. [CalViva Health — ABA Prior Authorization Request Form (24-990)](https://providerlibrary.healthnetcalifornia.com/content/dam/centene/healthnet/pdfs/providerlibrary/500232-ABA-Prior-Auth-Request-Form-CVH.pdf)
8. [Health Net — ABA Recommendation and Referral Form (24-989)](https://providerlibrary.healthnetcalifornia.com/content/dam/centene/healthnet/pdfs/providerlibrary/500231-ABA-Referral-Form-MCL.pdf)
9. [Health Net Medi-Cal — Coordination of Benefits Overview (updated 12/18/2024)](https://providerlibrary.healthnetcalifornia.com/medi-cal/provider-manual/coordination-benefits/overview-medi-cal.html)
10. [CHHS Open Data — Medi-Cal Managed Care Enrollment Report (August 2026)](https://data.chhs.ca.gov/dataset/medi-cal-managed-care-enrollment-report)
11. [Health Net Medi-Cal Provider Manual — Behavioral Health Overview (updated 12/5/2025)](https://providerlibrary.healthnetcalifornia.com/medi-cal/provider-manual/benefits/behavioral-health/overview-medi-cal.html)
12. [Health Net Medi-Cal — Requirements for Notification of UM Decisions (updated 7/4/2024)](https://providerlibrary.healthnetcalifornia.com/medi-cal/provider-manual/denial-notification/requirements-notification-utilization-management-decisions.html)
13. [DHCS APL 21-011 (Revised 8/31/2022) — Grievance and Appeals Requirements](https://www.dhcs.ca.gov/file/apl21-011-pdf/)
14. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes](https://www.ecfr.gov/current/title-42/section-438.210)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.