Submitting a Claim

Important Update: In an effort to help better serve our L.A. Care Provider Network, L.A. Care has contracted with Change Healthcare to become the exclusive clearinghouse for the submission of all your Electronic Data Interchange claims (EDI).

Change Healthcare Benefits

Making Change Healthcare our exclusive clearinghouse for the submission of electronic claims will provide you with the following benefits:

  • Allows our providers to directly submit electronic claims to Change Healthcare.Reduce administrative fees related to the submission of claims, eligibility, and claims status transactions.
  • In addition, providers will have the improved ability to verify electronic eligibility for our members via the 270/271 EDI Transaction and perform claim status lookup via the 276/277 Transaction.
  • Reduce provider administrative fees related to the submission of claims, eligibility, and claims status transactions.
    Access our step by step instruction video of how to use ConnectCenter
  • Allows L.A. Care the ability to create and customize the frontend edits to help you improve the submission of your data and ensure your claims are processed accurately and in a timely manner.
  • Allows our providers to submit electronic claims at no cost to you. Please note that using the free billing option will only be available to those providers that do not currently have a business relationship with Change Healthcare and will allow only the direct submission of electronic claims to L.A. Care.
  • Allows our providers to submit electronic attachments through Change Healthcare’s attachment portal. This functionality is currently being developed and will be available in the near future.
What You Need to Do
  • If you currently use Change Healthcare as your clearinghouse to send claims to us, no action or change is required.
  • If you are not currently submitting your L.A. Care claims through Change Healthcare but do submit claims for other health plans using Change Healthcare, please contact Change Healthcare and have them route your electronic claims to L.A. Care using Payer Id: LACAR or CPIDs 5988 and 6484.
  • If you currently do not have a business relationship with Change Healthcare and would like to sign-up with them for all your EDI business needs, please contact their support team at 800-527-8133
  • If you currently do not have a business relationship with Change Healthcare or submit your claims electronically and would like to take advantage of their free paper billing option, please go to https://connectcenter.changehealthcare.com and sign up to enter claims directly to Change Healthcare using the Connect Center portal.
  • For additional information using Connect Center to submit your claims at no cost, please access the following document

Though you may still continue using your current clearinghouse to submit electronic claims to L.A. Care for the next few weeks, you must fully transition all your electronic claim submissions to Change Healthcare no later than October 31, 2021. Failure to route your claims through Change Healthcare after this date will result in the rejection of your claims from your current clearinghouse.

If you have any further questions or experience any issues, you may reach out to Change Healthcare Support at 800-527-8133 (option 1) or send us an email.

 


L.A. Care requires that an initial claim be submitted to the appropriate Claims Department under a specific timeline.

Please check your contract to find out if there are specific arrangements.

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L.A. Care Health Plan offers Payspan® Health - A solution that delivers:

  • Electronic Funds Transfer (EFT)
  • Electronic Remittance Advice. 

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Claims Billing

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

W-9 Submission

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
Electronic Submission of Claims

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.

Hard Copy (Paper) Claim Submission by Mail

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

Acknowledgement of Claims

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). 

Professional and Supplier Claims

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.

Incomplete Claim

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

Provider Portal – Claim Status

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.

Claims Payment – Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA)

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.

Coordination of Benefits

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

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. 

Prohibition of Balance Billing

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.

Timely Filing Deadline

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.

Provider Disputes

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
Second Level Dispute

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.