Skilled Nursing Facility Resources

Q. How do I become a contracted provider?

A. If you are a skilled nursing facility that is interested in participating in the L.A. Care network, please submit a letter of interest to L.A. Care's Provider Network Management department via email or you can fill out the form online.

L.A. Care will review the letter of interest and contact you with a decision. If the letter of interest is approved, you will be notified to proceed with the contract submission, at which time L.A. Care will share the contracting process with you.

Q. How do I confirm whether I am contracted with L.A. Care? 

A. In order to confirm if you are part of the L.A. Care network, you can call the provider line at 1-866-522-2736.

Q. If the member has Medicare as the primary payer and L.A. Care Medi-Cal as secondary payer, do I have to be a contracted provider with L.A. Care to admit an L.A. Care member to my facility?

A. For Skilled Care Services:

If the member has Medicare Part A, the facility does not have to be contracted with L.A. Care Health Plan. Medicare will be responsible for facility costs. L.A. Care Medi-Cal will be responsible for coordination of benefits. However, if the patient has exhausted Medicare days and the secondary payer will be exercised, then the facility needs a financial agreement with L.A. Care. This can be through a contract or Memorandum of Understanding (MOU) or Letter of Agreement (LOA). Please request an MOU/LOA at the time of obtaining an authorization.

If the member has Medicare Part B only, the facility does need a financial arrangement with L.A. Care Health Plan. This can be through a contract or Memorandum of Understanding (MOU) or Letter of Agreement (LOA). Please request an MOU/LOA at the time of obtaining an authorization.

For Long Term Care Services:

When a member goes into long-term care, Medi-Cal becomes the primary payer for facility costs. The facility does need a financial arrangement with L.A. Care Health Plan. This can be through a contract, or Memorandum of Understanding (MOU) or Letter of Agreement (LOA). Please request an MOU/LOA at the time of obtaining an authorization.

Q. How often should I check eligibility for a member? 

A. L.A. Care recommends verifying eligibility frequently as the health plan, PPG and PCP assignments may change.

Q. How can I check eligibility for a member?

A. L.A. Care recommends that all providers check a member's eligibility in a two-step process.

1. Verify the member's eligibility through the Medi-Cal AEVS.

The health plan listed on the HCP field is the plan responsible for providing authorizations and processing claims.

Note that L.A. Care Health Plan directly manages members when both PHP and HCP fields are listed as "L.A. Care Health Plan".

2. Verify the member's assignment of PPG, PCP, and affiliated hospitals (as applicable) with L.A. Care.

You can obtain this information telephonically via IVR (866) 522-2736 or through L.A. Care's Provider Portal. 

Q. How do I register for access to the Provider Portal?

A. L.A. Care's Provider Portal is available for contracted providers.

If you are a contracted provider, you can request your Provider Portal login setup by emailing Provider Relations.

The email request should include the facility's:

• Organization Name (as listed in the contract with L.A. Care)
• NPI
• Address
• Your Name
• Title 
• email Address
• Phone Number

You will receive an email with an activation link within 10 business days.

Please note that the link requires activation within 24 hours of email receipt. After 24 hours, the link will become void and you will need to submit a new request.

Q. Who should I contact for questions regarding the eligibility information?

A. Please call our provider line at 1-866-522-2736. 

Q. Where do I get an authorization for Skilled Care?

A. You can obtain a skilled care authorization for an L.A. Care member from the member's assigned Medi-Cal PPG. There are exceptions where L.A. Care Utilization Management (UM) team authorizes for Medi-Cal members.

You can find out the member's assigned PPG through member eligibility verification. 

Q. Do I need an authorization for a bed hold?

A. Bed hold is a covered benefit under a member's Medi-Cal benefit. You are responsible for notifying the appropriate UM team when a member transfers to acute care.

An authorization will be issued for up to 7 days when a member is admitted to acute care.

Q. What are my responsibilities once an L.A. Care member is admitted to my facility? 

A. You are responsible for maintaining communication with the appropriate UM team on the member's progress. This includes submitting medical documentation once a week until the member is discharged from your facility.

Q. What is my responsibility when an L.A. Care member is ready for discharge?

A. You are responsible for notifying the appropriate UM team as soon as the medical team determines the member is ready for discharge.

You are responsible for submitting a discharge plan that includes referral to any services the member may need to discharge safely to his or her home. This may include, but not limited to, DME, home health, oxygen etc. The appropriate UM team will coordinate the services for the member. 

Q. What should I do if I have an open TAR from the State for a patient that became eligible with L.A. Care?

A. L.A. Care will honor all current TARs. The date of services on the TAR must cover the date the member became effective with managed care.

Once you identify through eligibility verification that the member is assigned to L.A. Care, you must notify L.A. Care's Medical Management Department at 1-877-431-2273 and fax referral to (213) 438-4877. 

You need to submit a copy of the member's face sheet in addition to the Approved/Modified TAR or adjudication response.

MLTSS will issue a six (6) month L.A. Care authorization five business days after receipt of all required documentation.

Q. What do I do if I have a new referral for a Long Term Care services?

A. You need to submit all required documentation to MLTSS by secured email or fax (213) 438-4877. This includes:

• LTC Referral Form indicating New Referral
• Copy of MD Order indicating LTC/Custodial
• Minimum Data Set (MDS)
• Current Interdisciplinary Care Plan (ICP)

MLTSS will issue an L.A. Care authorization five business days after receipt of all required documentation. 

If all of the above requested information is not provided, this may cause a delay in processing.

Q. What do I do if a patient is receiving skilled care but needs long term care?

A. In cases where an L.A. Care member was admitted to your facility for skilled care needs and transitioned to long-term care needs, then you must follow the new referral process.

MLTSS will issue an L.A. Care authorization five business days after receipt of all required documentation.

Q. I have an L.A. Care authorization for Long Term Care that has expired. What do I do?

A. You need to submit a LTC Referral Form indicating re-authorization and any supporting medical documentation to Medical Management Department by faxing it to (213) 438-4877. A Medical Management Department staff may request additional medical documentation to determine medical necessity.

Medical Management Department will issue an L.A. Care authorization five business days after receipt of all required documentation.

Q. Does L.A. Care cover durable medical equipment?

A. Yes, L.A. Care has a network of ancillary providers for all lines of business including Medi-Cal. This includes durable medical equipment (DME).

To request DME services, please submit a referral to the appropriate UM team.

Please check your contract to find out the arrangement regarding DME benefits.

Q. Does L.A. Care cover medications?

A. Yes, L.A. Care partnered with Navitus Health Solutions to manage the prescription drug benefit for all lines of business including Medi-Cal.

Please check your contract to find out the arrangement regarding medication benefits.

Q. Does L.A. Care offer transportation to members?

A. Yes, L.A. Care has partnered with a transportation vendor to manage non-emergency, medically necessary transportation for all lines of business including Medi-Cal.

Q. What are the types of transportation services available?

A. Our transportation vendor offers a range of transportation services to accommodate a member's needs including:

Non Emergency Medical (NEMT) 

The driver assists the member within the home or the provider's office (that is wheelchair or gurney).

Non Medical (NMT) 

The driver picks up and discharges the member to or from home. If applicable, the driver accommodates the member's escort who stays with the member in need of supportive care. 

For members with physical or medical conditions that require the use of specialized medical equipment that prevents them from using public transportation (oxygen tank or IV), you can arrange transportation with a non-emergency ambulance by advising the vendor representative. They will provide options for the member's specific medical needs. 

Q. What is the process to arrange non-emergency transportation for an L.A. Care member?

A. You can arrange non-emergency transportation for an L.A. Care member by contacting our transportation vendor at 1-877-431-2273.

If the member requires on-going non-emergency transportation, then the member's provider needs to complete and submit a PCS Form.  The transportation vendor will issue a four (4) month authorization for the member to utilize for medically necessary transport, as needed.

Please allow a minimum of four hours allocated time to pick up the member for urgent trips and discharges.

Q. Does L.A. Care offer Behavioral Health Services to members?

A. Yes, L.A. Care contracted with Carelon Behavioral Health to provide behavioral health services. 

Q. How does the member access continuity of care?

A. Yes, L.A. Care follows Continuity of Care regulations.

Physician

Upon the member's request, an L.A. Care member is eligible to continue to receive services from an out-of-network provider for primary and specialty care services up to twelve months for Medi-Cal benefits and six months for Medicare benefits.

Q. How do I complete a claim to L.A. Care?

A. L.A. Care requires that facilities use the UB-04 form to submit claims. L.A. Care has developed a SNF Billing Guide to assist skilled nursing facilities.

Q. Is there a timeline to submit an initial claim?

A. Yes, 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.

Q. Where do I submit a claim for an L.A. Care member?

A. You can submit claims for skilled and long-term care for an L.A. Care member to L.A. Care. 

There are exceptions for Medi-Cal members assigned to an affiliated hospital.

You can find out the member's assigned PPG through the members' eligibility verification system.

Q. How do I submit claims to L.A. Care?

A. You can submit claims to L.A. Care in one of two ways:

Paper Claims are submitted to L.A. Care must be mailed to:

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

Electronic Claims are accepted via officeally.com

In order to activate the account, you must register by:

• Visiting officeally.com and enter the Payer Identification code: LACAR
• Enable access by faxing a W-9 Form to L.A. Care at (213) 438-5732. Please include in the subject line Electronic Claim Activation  

Please allow 10 business days for the activation process before submitting claims electronically.

Q. When should I submit a resubmit a claim?

A. You may resubmit a claim when the original claim was denied due to:

• Claim was incomplete
• Incorrect coding 
• Incorrect billed amounts
• Additional information requested, but not received 

If you decide to resubmit a claim, please follow this checklist for adjudication:

• Providers have 12 months from the time the claim was denied for non-receipt of additional information to request "Resubmission" or "Reconsideration" of a claim
• All lines must be rebilled to ensure it is adjudicated appropriately
• Clearly label as "Resubmission" or "Reconsideration" at the top of the claim
• Use Black Ink
• Include a brief note describing reason for resubmission or corrections made
• Required: Include any additional supporting documentation
• DO NOT submit electronically

All re-submitted claims must be mailed to:

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

Q. Does L.A. Care provide Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA)?

A. Yes. All Practitioners can register to receive free electronic services through PaySpan® Health.

Registration: Click here.

Q. How can I submit a dispute or appeal?

A. You may dispute a claim if you believe it was incorrectly processed. L.A. Care has 45 business days from the date of receipt to respond to a dispute.

If you decide to dispute a claim, please follow this checklist for review:

• Dispute Claim Submission timeline is based on the contract, usually  up to 12 months from the last action of the claim.
• Submit Provider Dispute Resolution (PDR) Form with:
  • Copy of Initial Claim
  • Copy of Authorization
  • Supporting documentation and details for dispute

All PDRs submitted to L.A. Care must be mailed to:

L.A. Care Health Plan
Attn: Appeals Department
P.O. Box 811610
Los Angeles, CA 90081

Q. Does L.A. Care provide trainings for Skilled Nursing Facilities?

A. Yes, L.A. Care has monthly training  webinars for Skilled Nursing Facilities. They occur every third Thursday of the month.

If you have questions, please contact us via email.

Q. Can my facility get an on-site training?

A. Yes, our Provider Relations Skilled Nursing Unit conducts on-site trainings upon request. Please contact us via email.