Six-month Medi-Cal redeterminations start December 31, 2026. Roughly two million California members are at risk of losing coverage, most of them for paperwork reasons, not eligibility reasons. Every one is a patient who stops showing up and a claim that never gets paid.
We codify redetermination and CalAIM billing requirements into a deterministic rules engine that checks every patient record before a renewal date passes or a claim goes out. Your team gets a prioritized list of what needs attention, and why, in plain language.
Under H.R. 1, Medicaid expansion adults move from annual to six-month eligibility renewals effective December 31, 2026. California DHCS published its implementation plan in January 2026. There is no state option to delay this provision.
For behavioral health providers and FQHCs, this doubles the number of times each year a patient can fall out of coverage because a form did not get returned, and the population least equipped to manage paperwork is the population you serve.
Sources: H.R. 1 §71107; CMS SMD #26-001; California DHCS H.R. 1 Implementation Plan (January 30, 2026).
A patient’s redetermination date passes. Nobody flagged it. Nobody knew their address on file was stale. Coverage lapses mid-treatment, the patient stops coming, and sessions you already delivered become unbillable.
The ECM documentation was thorough. The care coordination happened. But the modifier did not match the managed-care plan’s requirement, and the claim came back denied weeks later, when reworking it costs more than it recovers.
DHCS asks how a service met medical necessity. The documentation exists somewhere across three systems and a shared drive. Assembling the answer takes a week of staff time you did not budget.
We take the requirements your organization actually operates under (H.R. 1 redetermination rules, CalAIM ECM and Community Supports billing standards, and your managed-care plan’s specific modifier requirements) and codify them into deterministic rules that evaluate every record before it matters.
Every patient scored against their renewal date, contact information currency and documentation completeness. Your care coordination team gets a weekly prioritized outreach list: who needs attention, what is missing and how many days remain.
Every claim checked against the documentation, coding and modifier requirements for that service, that payer and that program, before it is submitted, not after it is denied.
When something fails a check, your billing specialist sees what failed, why it matters and the steps to fix it, with a citation to the exact DHCS or plan requirement behind it. No decoder ring required.
Every evaluation is timestamped and immutable. When DHCS or a managed-care plan asks how a determination was made, the answer is already assembled: data, rule, reasoning step, outcome.
SUD treatment programs, outpatient mental health practices and community behavioral health agencies where Medi-Cal is the majority of revenue. Your patients are disproportionately affected by redetermination churn, and CalAIM documentation requirements are the most complex in the state.
FQHCs managing renewal navigation across large patient panels, with community health worker teams doing it patient by patient. We turn that into a systematic, prioritized weekly workflow.
Organizations responsible for network-wide compliance performance, where a provider’s documentation gap becomes your DHCS contract problem.
Enterprise pharmacy operations platformFor Luveo Health we codified 28 compliance rules across 7 operational workflows (DEA, DSCSA, HIPAA, USP 797 and state Board of Pharmacy) and layered a governed copilot that translated every outcome into cited, plain-language guidance for pharmacy technicians.
Across a 30-scenario structured evaluation: zero hallucinated rule keys, zero fabricated regulatory citations and zero guardrail violations. Delivered in two four-week cycles.
Read the case study →If we can scope it into a four-week cycle, we will tell you exactly what that includes and what it costs. If we cannot, we will tell you that too.
Book a 30-minute scoping call →Hi. Ask me about our services, the four-week cycle, PHI and security, or the Luveo case study. Every answer links to where it comes from.