Claims Payment Policy and Practices
Out-of-network liability, balance billing
Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with L.A. Care. A health care professional who is out of network can set a higher cost for a service than professionals who are in your network of providers. Depending on the health care professional, the service could cost more or not be paid for at all by L.A. Care. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what L.A. Care does not cover. Balance billing may be waived for emergency services received at an out of-network facility.
Enrollee Claim Submission
A claim is a request to an insurance company for payment of health care services. Usually, providers file claims with us on your behalf. If you received services from an out-of-network provider, the provider must submit a claim to L.A. Care in order for the provider to get reimbursed. There are time limits on how long providers have to submit claims. The claim filing time limit for L.A. Care is 180 days from the date of service. If the provider does not submit a claim to L.A. Care and you paid for services rendered, you can submit a claim for reimbursement to L.A. Care.
To file a claim for reimbursement, complete a request using our online grievance form.
Write, visit or call L.A. Care.
L.A. Care Health Plan
Member Services Department
1055 W. 7th Street, 10th Floor
Los Angeles, CA 90017
Grace Periods claims pending
You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be canceled. For most individual health care plans, if you do not pay your premium on time, you will receive a 30-day grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium.
If you have an individual HMO plan in California, we will pay your claims during the 30-day grace period; however, your benefits will terminate if your delinquent premium is not paid by the end of that grace period.
If you are enrolled in an individual health care plan offered through Covered California and you receive an advance premium tax credit, you will get a 3-month grace period and we will pay all claims for covered services that are submitted properly during the first month of the grace period. During the second and third months of that grace period, any claims you incur may be pended. If you pay your full outstanding premium before the end of the 3-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the 3-month grace period, your coverage will terminate, and we will not pay for any pended claims submitted for you during the second and third months of the grace period. Your provider may balance bill you for those services.
A retroactive denial is the reversal of a claim we have already paid. If we retroactively deny a claim we have already paid for you, you will be responsible for payment. Some reasons why you might have a retroactive denial include having a claim that was paid during the second or third month of a grace period or having a claim paid for a service for which you were not eligible.
You can avoid retroactive denials by paying your premiums on time and in full, and making sure you talk to your provider about whether the service performed is a covered benefit. You can also avoid retroactive denials by obtaining your medical services from an in-network provider.
Recoupment of Overpayments
If you believe that we have overbilled you for your premium, or you overpaid your monthly premium, please contact our Member Service Department for reimbursement.
To request a refund, please contact L.A. Care Health Plan Member Services at 1-855-270-2327 (TTY 711) 24 hours a day, 7 days a week, including holidays.
Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities
L.A. Care must approve some services before you obtain them. This is called prior authorization or preservice review. For example, any kind of inpatient hospital care (except maternity care) requires prior authorization. If you need a service that we must first approve, your in-network doctor will call us for the authorization. If you don’t get prior authorization, you may have to pay up to the full amount of the charges. The number to call for prior authorization is included on the ID card you receive after you enrolled. Please refer to the specific coverage information you receive after you enroll. We typically decide on requests for prior authorization for medical services within 72 hours of receiving an urgent request or within 15 days for non-urgent requests.
Drug exception timeframes and enrollee responsibilities
Sometimes our members need access to drugs that are not listed on the plan's formulary (drug list). These medications are initially reviewed by L.A. Care through the formulary exception review process. The provider can submit the request to us by faxing the Pharmacy Formulary Exception Request form.
For standard exception review of Drug requests where the request was denied, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request. If the drug is denied, you have the right to an external review.
Explanation of Benefits (EOBs)
Each time we process a claim submitted by your health care provider, we explain how we processed it on an Explanation of Benefits (EOB) form.
The EOB is not a bill. It explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.
Access information on how to read your EOB (English)
Coordination of benefits (COB)
Coordination of benefits, or COB, is required when you are covered under one or more additional group or individual plans, such as one sponsored by your spouse's employer. An important part of coordinating benefits is determining the order in which the plans provide benefits. One plan provides benefits first. This is called the primary plan. The primary plan provides its full benefits as if there were no other plans involved. The other plans then become secondary. Further information about coordination of benefits can be found in your benefit booklet.