Provider FAQs

How to Reach Us

If you are a medical professional and have a question regarding the Medi-Cal Program, please call our Provider Information Line at 1-866-LA-CARE6 (1-866-522-2736).

If you would like paper copies of any of the information available on the website, please contact us at 1-866-LA-CARE6 (1-866-522-2736).
 

Frequently Used Resources

Frequently Discussed Topics

Case Management Services

Case Management is a program for assisting members with complex care needs, often due to complications from chronic conditions such as diabetes, heart conditions, or a combination of such illnesses.

These needs include help with navigating the health care system, identifying and engaging community resources, benefit management, or transitions to other levels of care.

For more information about case management, or to make a referral, call the L.A. Care UM Department at 1-877-431-2273 and ask to speak with a Case Manager.

Disease Management Program Information

L.A. Care Health Plan currently offers an asthma disease management program called "L.A. Cares About Asthma" to our Healthy Families, Healthy Kids, Medicare SNP and Medi-Cal members directly enrolled with L.A. Care.

Your L.A. Care members in these programs that are identified with asthma according to our data are automatically enrolled into this program. Participation is voluntary, and patients may opt out at any time. Program participants are identified and stratified by severity levels monthly and receive health education materials on a regular basis. High risk members are eligible to receive a phone call or home visit by our asthma care manager.

Your practice can use these disease management services by referring your L.A. Care Healthy Families, Healthy Kids, Medicare SNP and Medi-Cal (directly enrolled with L.A. Care) patients with asthma into the program. You may also receive a fax asking to verify the classification of your members in the Asthma Disease Management Program. Please review, complete and return the fax to (213) 438-4860.

L.A. Care is offering a diabetes disease management program (L.A. Cares About Diabetes) for Healthy Kids, Medi-Cal (directly enrolled with L.A. Care), and Medicare SNP members. Members can receive enhanced heath education, telephonic coaching from a nurse, and information on social services to help them manage their conditions. L.A. Care has contracted with Healthways, a disease management vendor to provide this service. Physicians can call (866) 756-2048 to refer members with diabetes or complex conditions who are enrolled in direct lines of business. Eligibility criteria will apply.

For more information about disease management, please contact the Asthma Resource Line at (213) 694-1250 x5426 regarding Asthma and Maria Casias, RN, at (213) 694-1250 x4312 regarding Diabetes.

Policy to freely communicate with patients about their treatment

Policy encouraging practitioners to freely communicate with patients about their treatment, regardless of benefit coverage limitations and specialist termination notification

L.A. Care has recently amended practitioner and provider contracts to encourage practitioners to freely communicate with patients about their treatment, including medication treatment options, regardless of benefit coverage limitations; and to require that practitioners and facilities:

  • Cooperate with L.A. Care and Plan Partner Quality Improvement activities.
  • Provide L.A. Care and its Plan Partners access to practitioner or facility medical records, to the extent permitted by state and federal law.
  • Maintain the confidentiality of member information and records.

The contract amendment also requires specialists and specialty group practices to provide timely notification to L.A. Care’s members who have been under the ongoing care of a terminating specialist or an entire specialty group. Our contracts with specialists and specialty group practices outline which party is responsible for notifying those members affected by the termination prior to the effective date of termination.

You can find additional information regarding notification of specialist termination in your provider manual. If you would like paper copies of any of the above information, please contact us at 1-866-LA-CARE6 (1-866-522-2736).

Requirement that practitioners and facilities cooperate with QI activities

Requirement that practitioners and facilities cooperate with QI activities; provide access to their medical records, to the extent permitted by state and federal law, maintain confidentiality of member information and records, and allow plan to use provider group/practitioner performance data.

L.A. Care has recently amended practitioner and provider contracts to encourage practitioners to freely communicate with patients about their treatment, including medication treatment options, regardless of benefit coverage limitations; and to require that provider groups, practitioners and facilities:

  • Cooperate with L.A. Care and Plan Partner Quality Improvement activities.
  • Provide L.A. Care and its Plan Partners access to practitioner or facility medical records, to the extent permitted by state and federal law.
  • Maintain the confidentiality of member information and records.
  • Allow plan to use provider group/practitioners/facilities to use performance data (e.g., quality improvement activities, public reporting to consumers, preferred status designation on the network, and reduced member cost sharing).

The contract amendment also requires specialists and specialty group practices to provide timely notification to L.A. Care's members who have been under the ongoing care of a terminating specialist or an entire specialty group. Our contracts with specialists and specialty group practices outline which party is responsible for notifying those members affected by the termination prior to the effective date of termination.

You can find additional information regarding notification of specialist termination in your provider manual. If you would like paper copies of any of the above information, please contact us at 1-866-LA-CARE6 (1-866-522-2736).

Policy on Notification of Specialist Termination

L.A. Care has recently amended practitioner and provider contracts to encourage practitioners to freely communicate with patients about their treatment, including medication treatment options, regardless of benefit coverage limitations; and to require that practitioners and facilities:

  • Cooperate with L.A. Care and Plan Partner Quality Improvement activities.
  • Provide L.A. Care and its Plan Partners access to practitioner or facility medical records, to the extent permitted by state and federal law.
  • Maintain the confidentiality of member information and records.

The contract amendment also requires specialists and specialty group practices to provide timely notification to L.A. Care’s members who have been under the ongoing care of a terminating specialist or an entire specialty group. Our contracts with specialists and specialty group practices outline which party is responsible for notifying those members affected by the termination prior to the effective date of termination.

You can find additional information regarding notification of specialist termination in your provider manual. If you would like paper copies of any of the above information, please contact us at 1-866-LA-CARE6 (1-866-522-2736).

Policy regarding your rights during the credentialing/recredentialing process

Policy regarding your rights during the credentialing/recredentialing process including to review information and correct erroneous information submitted to support your credentialing application, as well as obtain information about the status of your application; and how to exercise these rights

L.A. Care Health Plan (L.A. Care) recognizes practitioner rights in the credentialing and recredentialing processes. L.A. Care’s policy is that practitioners have the right to:

  • Review information submitted to support their credentialing and recredentialing application
  • Correct erroneous information
  • Upon request, to be informed of the status of their credentialing or recredentialing application

L.A. Care notifies practitioners of these rights via the application and reapplication and the provider web site.

Addendum C of the California Participating Physician Application (CPPA) which is used for all practitioners at credentialing and recredentialing must be signed by the practitioner.  By signing Addendum C, the practitioner attests to understanding the credentialing and recredentialing processes including his or her right to and the process to:

  • Review information obtained as part of the credentialing and recredentialing processes.
  • Correct erroneous information.
  • Obtain information about the status of his or her application or reapplication.

L.A. Care implements processes to allow practitioners to exercise these rights in the following manner:

  • Credentialing staff contact the practitioner to clarify unclear information.

Any verbal clarification provided by the practitioner is documented in the practitioner’s file, along with the date and signature of the individual obtaining the information.  Additional information or documents provided by the practitioner are date stamped and placed in the practitioner’s file.

  • Credentialing staff contacts the practitioner by telephone, mail or facsimile about any differences between verified information and that provided by the practitioner.

Any verbal clarification provided by the practitioner is documented in the practitioner’s file along with the date and signature of the individual obtaining the clarification.  Any additional information or documents provided by the practitioner are date stamped and placed in the practitioner’s file.

  • The practitioner may review information obtained by L.A. Care as part of the credentialing or recredentialing process.

A copy of the documents may be provided to the practitioner, except that peer reference documents and other peer material protected from disclosure by law may not be provided.

The practitioner may request to review such information at any time by sending a written request via letter or facsimile to:

The Manager of Credentialing
L.A. Care Health Plan
1055 West 7th Street, 10th Floor
Los Angeles, California 90017
Fax Number: (213) 623-8987

The Manager of Credentialing will notify the practitioner within 72 hours of receipt of a request to review information of the date and time when such information will be available for review. The practitioner must review the information at the L.A. Care office.

  • The practitioner may amend any erroneous information.

The practitioner must submit a detailed written explanation of the correction via letter or facsimile to:

The Manager of Credentialing
L.A. Care Health Plan
1055 West 7th Street, 10th Floor Los Angeles, California  90017 Fax Number: (213) 623-8987

The practitioner’s response must occur within: 48 hours of L.A. Care’s notification to the practitioner of a discrepancy, or within 24 hours of a practitioner’s review of his or her credentials file.

  • The practitioner may request information about the status of his or her application or reapplication at any time by contacting the Credentialing Department by mail or facsimile.

The Manager of Credentialing
L.A. Care Health Plan
1055 West 7th Street, 10th Floor
Los Angeles, California  90017

Fax Number: (213) 623-8987

  • L.A. Care informs practitioners in writing of Credentialing/Peer Review Subcommittee decisions within 60 calendar days of the Committee’s decision, places a copy of the notification in the practitioner’s file, and enters the date of the Credentialing/Peer Review Subcommittee decision into the credentialing database.
Disease Reporting in California

Under the California Code of Regulations, Title 17 (Section 2500), public health professionals, medical providers and others are mandated to report approximately 85 diseases or conditions to their local health department. Additionally, anyone in charge of any type of school is also required to report these diseases (Section 2508), as are laboratories (Section 2505).

Why report?

The primary objectives of disease surveillance are to:

  1. Protecting the health of the public
  2. Determine the extent of morbidity within the community
  3. Evaluate risk of transmission
  4. Intervene rapidly when appropriate

Delay or failure to report.

Delay or failure to report communicable diseases has contributed to secondary transmission in the past.  Under the California Code of Regulations, Title 16, (Section 1364.10), failure to report a communicable disease is a misdemeanor punishable by a fine of not less than $50 nor more than $1,000, or by imprisonment for a term of not more than 90 days, or both.  Each day the violation is continued is a separate offense. The Medical Board of California has made failure to report in a timely manner a citable offense under California Business and Professions Code (Section 2234), "Unprofessional Conduct."

For a list of reportable diseases and reporting forms, please visit the Los Angeles County Department of Health Services Acute Communicable Disease Control department website at http://lapublichealth.org/acd/cdrs.htm