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.
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]
The questions that decide whether a family can start with Health Net Community Solutions (Medi-Cal) / CalViva Health, and what they have to bring. Each maps onto something intake should ask on the first call.
"Member/enrollee is < 21 years old and medically stable" (CA.CP.BH.104). No minimum age.[1]
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]
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]
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]
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]
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]
"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]
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.
Coverage decides whether Health Net Community Solutions (Medi-Cal) / CalViva Health pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
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]
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]
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]
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]
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]
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.
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.
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.
Submit a new complete PA request with a letter explaining the clinical reason — addendums are no longer accepted, and the existing authorization is ended.
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.
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