If you paid for services you already got, you might qualify to be reimbursed (paid back) if you meet all of the following conditions:
- The service you got is a covered service that L.A. Care is responsible for paying. L.A. Care will not reimburse you for a service that L.A. Care does not cover.
- You got the covered service after you became an eligible L.A. Care member.
- You ask to be paid back within one year from the date you got the covered service.
- You show proof that you paid for the covered service, such as a detailed receipt from the provider.
- You got the covered service from a Medi-Cal enrolled provider in L.A. Care‘s network. You do not need to meet this condition if you got emergency services, family planning services, or another service that Medi-Cal allows out-of-network providers to perform without pre-approval (prior authorization).
- If the covered service normally requires pre-approval (prior authorization), you need to give proof from the provider that shows a medical need for the covered service.
L.A. Care will tell you if they will reimburse you in a letter called a Notice of Action (NOA). If you meet all of the above conditions, the Medi-Cal-enrolled provider should pay you back for the full amount you paid. If the provider refuses to pay you back, L.A. Care will pay you back for the full amount you paid. We must reimburse you within 45 working days of receipt of the claim.
If the provider is enrolled in Medi-Cal but is not in the L.A. Care network and refuses to pay you back, L.A. Care will pay you back, but only up to the amount that FFS Medi-Cal would pay. L.A. Care will pay you back for the full out-of-pocket amount for emergency services, family planning services, or another service that Medi-Cal allows to be provided by out-of-network providers without pre-approval (prior authorization).
If you do not meet one of the above conditions, L.A. Care will not pay you back.
L.A. Care will not pay you back if:
- You asked for and got services that are not covered by Medi-Cal, such as cosmetic services.
- The service is not a covered service for L.A. Care.
- You have an unmet Medi-Cal Share of Cost.
- You went to a doctor who does not take Medi-Cal and you signed a form that said you want to be seen anyway and you will pay for the services yourself.
- You have Medicare Part D co-pays for prescriptions covered by your Medicare Part D plan.
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