*Disclaimer: Please use this online look-up tool to check if a code requires an authorization or referral when L.A. Care Health Plan (not the Participating Physician Group or PPG), is responsible for the authorization. It is important to note that certain services will ALWAYS require an authorization from L.A. Care Health Plan such as: clinical trials, community based adult services (CBAS), experimental services, inpatient level of care (excluding admissions for the birth of a child), long term care (LTC) rehabilitation, non-contracted providers (other than dialysis), recuperative care, skilled nursing facility (SNF), transplant, unlisted procedures/codes, and medical supplies or items exceeding maximum allowable benefit or frequency limits.
Prior authorization is not required for emergency services, urgent care visits, sensitive services (which includes family planning), sexually transmitted disease services, abortion, minor consent services, human immunodeficiency virus (HIV) testing, basic prenatal care services, routine obstetric services, counseling (psychotherapy) and medication management for behavioral health conditions, primary and preventive adult/pediatric services.
To ensure payment, Providers are required to confirm member eligibility prior to providing services as payment is made only if the member is eligible at the time of service.
All claims submitted for services are subject to claims payment and Payment Integrity policies. Please contact the L.A. Care Provider Call Center at 1-877-431-2273 if you have any questions.