DHCS warns assisted living waiver facilities of denials and reprocessing
Published November 8, 2026 · Coverage November 1–7, 2026, Pacific · High priority
In a notice published October 9, 2026, DHCS said claims for Assisted Living Waiver (ALW) services may be non-payable due to non-compliance with program requirements, that it is reviewing previously paid claims, which may result in the reprocessing of claims that were erroneously paid, and that it will follow up with additional information tailored to specific facilities that have non-payable claims. To prevent claim denials, the notice says facilities must verify ALW eligibility before delivering services and submitting claims, using the approved processes outlined by DHCS and their Care Coordination Agency, fully comply with all ALW standards, policies and contract requirements, submit claims with correct procedure codes and modifiers, consistent with program guidance referenced in ALW program integrity correspondence, and review internal processes for accurate claiming and documentation; it states no agency deadline. First reported in the October 11 edition.
Current status
DHCS's notice, titled "Non-Payment of Inappropriate Claiming for Members Not Enrolled in the ALW Program", was still posted when it was opened in a browser on November 10, 2026 and showed no updated date. Whether DHCS has issued a later notice was not checked, and current status beyond that notice is unverified.
Who this affects
Assisted Living Waiver (ALW) facilities and Care Coordination Agencies billing Medi-Cal; health systems that operate or contract with them (inference).
Why it matters
Per the October 9 notice, the exposure is non-payment of Assisted Living Waiver claims that do not meet program requirements, and possible reprocessing of claims DHCS finds were erroneously paid.
Required actions
- The October 9 notice says that, to prevent claim denials, facilities must ensure they are verifying Assisted Living Waiver eligibility before delivering services and submitting claims, fully complying with program standards, policies and contract requirements, submitting claims with correct procedure codes and modifiers, and reviewing internal processes for accurate claiming and documentation.
Recommended action
- Validate eligibility and service evidence before billing; reconcile prior payments and preserve facility-specific correspondence.
- Send questions to the DHCS ALW claims support channel named in the notice, with the facility name and NPI.
Implementation playbook
- Check the Medi-Cal provider news page for any later notice on this subject, since this entry verified only that the October 9 notice is still posted. Owner: Compliance. Due: 2026-11-17.
- Match active Assisted Living Waiver members to approved eligibility confirmation and care-coordination records. Owner: Case Management. Due: 2026-11-20.
- Sample billed services, modifiers and supporting documentation and correct any non-compliance found. Owner: Revenue Cycle. Due: 2026-11-20.
- Reconcile any claims DHCS reprocesses and escalate facility-specific DHCS correspondence. Owner: Finance. Due: 2026-12-04, then monthly.
Scope and timing
- Authority status
- Announced
- Responsible owner
- Revenue Cycle (affected: Case Management, Compliance, Finance)
- Publication date
- 2026-10-09
- Other dates
- No agency deadline stated; DHCS follow-up is facility-specific
Not established
Evidence of the notice is a rendered-text browser capture made on November 10, 2026. Program integrity correspondence the notice refers to was not seen. Any facility-specific follow-up from DHCS is outside public sources. The playbook dates are planning dates set by this briefing.
Earlier article: October 11, 2026 edition →
Sources
Complete edition and supplemental material
This article in the complete report →
Executive triage, source-coverage limitations, context and forward horizons remain in the complete report.
Read the entire Medicare & Medicaid Sweep report →