Enforcement of Enrollment Mandate for Medi-Cal Prescribers, Including for Pharmacy Claims
Beginning June 26, 2026, the Department of Health Care Services (DHCS) will deny pharmacy claims and prior authorizations if the prescribing provider is not enrolled in Medi-Cal Fee-For-Service (FFS) under their individual Type 1 NPI, regardless of the provider’s participation in managed care or Medicare. Pharmacies will not be paid for dispensing medication to Medi-Cal members if the prescriber is not properly enrolled.
Prior practice allowed providers to enroll in Medi-Cal individually only if they planned to directly bill Medi-Cal for services. As part of the Affordable Care Act, in 2013, federal and state law required all providers who order, refer, or prescribe services for Medi-Cal beneficiaries to be enrolled in the Medi-Cal program, even when they did not submit direct claims themselves. However, the DHCS has not consistently enforced the rule for pharmacy claims.
The enforcement change aligns with DHCS’s overall enrollment mandate. This mandate, effective July 23, 2026, requires all providers who are currently enrolled in Medicare and order, refer, or prescribe services to Medi-Cal members to be separately enrolled in Medi-Cal. DHCS has clearly stated that enrollment in Medicare alone in not enough for participation in California’s Medi-Cal program for the sole purpose of ordering, referring, or prescribing, and that compliance with federal and state requirements are expected moving forward. For more information, see DHCS notice “Updated Medi-Cal Requirements for Ordering/Referring/Prescribing Provider Forms and Procedures” at https://www.dhcs.ca.gov/updated-medi-cal-requirements-for-ordering-referring-prescribing-provider-forms-and-procedures/.
DMHC Complaint Lookback Period Reduced from Four Years to 30 Months
Effective July 1, 2026, the Department of Managed Health Care (DMHC) will decrease the lookback period for provider complaints from four (4) years to 30 months. Complaints for older disputed claims must be filed before June 30, 2026, to preserve eligibility. Beginning July 1, 2026, claims with a last date of service older than 30 months will not be accepted by the DMHC online submission portal.
