Submitting a Claim

All paper claims must be submitted on a CMS 1500 form for professional services and UB-04 form for facility services. 

Clean Claims Billing Requirements
Before L.A. Care can process your claim, it must include all required information, where applicable and be "clean" of any errors. Please use the following document as a guide to identify the requirements for a clean claim submission.

Clean Claim Billing Requirements CMS 1500
Clean Claim Billing Requirements UB 04

L.A. Care Health Plan requires a current W-9 form to be on file in order to process any claims. The W-9 form will be used to verify your mailing/remittance address.

There are three ways Providers can submit their W-9 form to L.A. Care:

1. Email to PDU_Requests@lacare.org
2. Fax W-9 Form (without paper claim) to 213-438-5732
3. Mail (with or without paper claims) to:

L.A. Care Heath Plan
Attention: Claims Department
P.O. Box 811580
Los Angeles, CA 90081 

All checks, claims remittance advices and 1099s will be mailed to the address listed on the W-9, as applicable.

Please note that an updated W-9 is required but not limited to the following changes:

• Mailing Address,
• Legal Business Name,
• Ownership
• TAX ID Number

Advantages of using EDI

Several immediate advantages can be realized by exchanging documents electronically, here are a few:

Ability to submit 24/7

L.A. Care accepts all claims electronically, including professional and institutional related submissions 24 hours a day, seven days a week.

Reduction of data entry and payment errors

Claims submitted electronically benefit from earlier detection of billing errors.  If your claim fails due to any pre-pass edit, the claim is returned back to your office for correction.  This editing reduces the likelihood of your claim being rejected or denied for payment once it enters the processing system.

Immediate verification of claims received

Receive immediate acknowledgement of claims received and confirmation through your clearinghouse within two days as to if claims have been accepted  or rejected.

In order to take advantage of EDI, you'll need to register with Change Health Care clearinghouse and reference L.A. Care's Payer ID "LACAR". 

L.A. Care Providers must bill with the most up-to-date current coding available for the date of services rendered.

Providers can send hard copy (paper) claims via mail to the address below:

L.A. Care Health Plan
Attention: Claims Department
P.O. Box 811580
Los Angeles, CA 90081

L.A. Care shall identify and acknowledge the receipt of each claim, whether or not complete, and disclose the recorded date of receipt to the billing practitioner as follows:

• EDI Claim, within 2 working days of the date of receipt of the claim.
• Paper Claim, within 15 working days of postmarked envelope.

If you have any questions about a claim submission, please consult the provider portal or contact the L.A. Care Provider Service Line at 1.888.4LA.CARE (1.888.452.2273). 

Practitioners sending professional and supplier claims to L.A. Care Health Plan on paper must use Form CMS 1500 in the latest valid version. This form is maintained by the National Uniform Claim Committee (NUCC), an industry organization in which CMS participates.

An incomplete claim is defined as any claim with incomplete, missing or invalid information. 

The L.A. Care Provider Portal is the preferred method for contracted practitioners to check claims status.

You can find information on how to access the L.A. Care provider portal in the Provider Portal section of the handbook. The secondary method to check claims status is by calling 1-866-LA-CARE6 (1-866-522-2736). For L.A. Care Community Access Network please call 1-844-361-7272.

All Practitioners can register to receive free electronic services through PaySpan® Health such as:

• Electronic Funds Transfers (EFTs)
• Electronic Remittance Advice (ERAs)

Registration: Click here.
 

After Registration, log into your account and follow these steps to add L.A. Care as a new payer to your account. User must have "Manage Reg Codes" feature in order to access this manage preferences button.

1. Log into your PaySpan account here
2. Click "Your Payments"
3. Click "Reg Codes" under the Manage panel
4. The Manage Reg Codes screen will display
5. Click the "Manage Preferences" button on the right side of the page
6. Use the drop-down menu to designate a Preferred Account for all tax ID numbers listed

Please allow 10 business days for full activation and initiation of EFT/ERA receipt. Provider Services Specialists at Pay Span are available to provide support for questions or issues, Monday through Friday from 8 a.m. to 8 p.m., Eastern Time.
Please call +1-877-331-7154.

In accordance with requirements of the Balanced Budget Act of 1997, as a secondary payer, L.A. Care will pay deductibles, co-insurance and co-payments for Medi-Cal covered services up to the lower of our fee schedule or the Medicare/other insurance allowed amount.

California law limits Medi-Cal's reimbursements for a crossover claim to an amount that, when combined with the Medicare payment, should not exceed Medi-Cal's maximum allowed for similar services (Welfare and Institutions Code, Section 14109.5). When a Member has other health insurance, whether it is Medicare, a Medicare HMO or a commercial carrier, L.A. Care will coordinate payment of benefits. These other insurers are considered the primary payer, and L.A. Care is the secondary or last payer.

Balance billing is when a practitioner charges beneficiaries for Medi-Cal covered services. Balance billing L.A. Care Members is prohibited by law.

Contracted practitioners cannot collect reimbursement from a L.A. Care Member or persons acting on behalf of a Member for any services provided, except to collect any authorized share of cost co-insurance, co-payment or deductibles when applicable. 

Practitioners participating in Medi-Cal and/or Medicare are prohibited from balance billing any L.A. Care Member eligible for Medi-Cal and/or Medicare. Network practitioners who engage in balance billing are in breach of their contract with L.A. Care.

Practitioners who engage in balance billing may be subject to sanctions by L.A. Care, CMS, DHCS and other industry regulators.

L.A. Care cannot impose a timeframe for receipt of the first "initial claim" submission that is less than 180 days for contracted practitioners after the date of service for timely filing for a new claim. L.A. Care may deny a claim that is submitted beyond the claim filing deadline.

A practitioner has a right to file a dispute in writing to L.A. Care within 365 day from the date of service or the most recent action date, if there are multiple actions. L.A. Care makes available to all practitioners a fast, fair and cost-effective dispute resolution mechanism for disputes regarding invoices, billing determinations or other contract, non-contracted issues. The dispute resolution mechanism is handled in accordance with applicable law and your agreement. A provider dispute is a written notice to L.A. Care challenging, appealing or requesting reconsideration of a claim. The following are examples of disputes:

• Claims payment disputes: challenging, appealing or requesting reconsideration of a claim (or bundled group of claims)
• Benefit determination disputes: seeking resolution of a benefit determination
• Payment of a claim
• Denial of a claim
• Timely filing denial
• Seeking resolution of a billing determination
• Seeking resolution of another contract dispute
• Disputing a request for reimbursement of an overpayment to a claim

If you remain unable to resolve your billing and payment issues L.A. Care makes available to all practitioners a second level dispute process. Second level disputes must be sent to the following address:

L.A. Care Health Plan
Attention: Provider Disputes
P.O. Box 811610
Los Angeles, CA 90081

• L.A. CARE will acknowledge receipt of disputes by mail within 15 calendar days of the date of receipt by L.A. Care.
• L.A. Care will issue a written determination stating the outcome decision for its determination within.
• 45 calendar days after the receipt of a clean dispute.