Manuals and Forms

Provider Manuals

 

To help you better understand our guidelines, policies and procedures, L.A Care issues a manual to its providers each year. You can review a PDF version by selecting the appropriate manual on the Resources links.

 

Provider Forms

 

Below are the most frequently requested forms for L.A. Care Providers. If you have a suggestion for how we can improve any of the available forms, please contact Provider Support.

Behavioral Health Forms

Functional Behavioral Assessment/Progress Report


Visit our Behavioral Health web page for program information.

Case Management Forms

Care Management Referral Form

ECM Benefit Member Referral Form


Learn more program information at Enhanced Care Management.

Claims Forms

CMS 1500 Claim Form 
CMS 1500 Claim Form Instructions
Provider Dispute Resolution Request Form for Medicare DSNP Plan
Provider Dispute Resolution Request Form for Medi-Cal, PASC-SEIU Plan and L.A. Care Covered


Visit our Claims web page for more information.

Disease Management Forms

CVD Referral Form

Employee Language Skills Self-Assessment Form

Language Skills Self-Assessment Form

Health Education Forms

Health Education Referral Form
Medical Nutrition Therapy (MNT) Referral Form
CS Medically Tailored Meals Referral Form
Doula Benefit Provider Recommendation Form


Find more Health Education resources.

Initial Health Assessment Forms
Interpreter Poster
Managed Long Term Services and Supports

Caregiver Support Services: Service Authorization Request Form
CBAS Face to Face Assessment Request (CEDT) Form 
Environmental Accessibility Adaptations (EAA) Service Authorization Request (SAR) Form
Environmental Accessibility Adaptations (EAA) Qualified Lead Form
Environmental Accessibility Adaptations (EAA) Physician Order Form
MLTSS Referral Form
Palliative Care Referral & Screening Tool

Member Demographic Data Report

Member Demographic Data Report

Patient Interpreter Services Labels

Preferred Language Labels (Sized for Avery 5160)
Interpretation Request/Refusal Labels (Sized for Avery 5160)

Pharmacy & Formulary Forms

MedWatch Form
Ralphs Pharmacy Form
Ralphs Pharmacy Form (Spanish)


Visit our Pharmacy Services web page for more information.

Prescription Drug Prior Authorization Request Forms

Medicare Plus (DSNP) Coverage Determination Form

Provider Portal Resources

Provider Portal Reference Guide


Go to the Provider Portal.

Reference Guide

ELDA Technical Bulletin
Coding Reference Guide for Acute Respiratory Conditions
Provider Authorization and Billing Reference Guide
Medi-Cal Shared Risk Amendment Template
SNF Authorization and Billing Guidance
Hospital UM Related Fax Information for All L.A. Care Members
SNF Related Fax Information for All L.A. Care Members

Social Services Forms

Homeless and Housing Support Services Program (HHSS) Form
Homeless and Housing Support Services Program (HHSS) Reauthorization Form
Housing Deposits Quick Reference Guide
Housing Deposits Services Request for Funds Form
L.A Care HHSS Community Supports Program Quick Reference Guide
L.A. Care Recuperative Care Community Supports Program Quick Reference Guide
Recuperative Care Prior Authorization Request Form
Request for Recuperative Care Extension Form
Community Health Worker Benefit Recommendation Form


For more program information, visit Community Supports.

Utilization Management Forms

Provider Prior Authorization Tool
Prior Authorization Request Forms
Difficult Placement Authorization Request Form
Difficult Placement Authorization Request Form Checklist
Higher Level of Care (HLOC) Authorization Form
Hospital Priority & Type of Clinical Service Requested Fax Form
Hospital UM Contact Information (Authorization Contact Cheat Sheet)
SNF UM Contact Information (Authorization Contact Cheat Sheet)
SNF Authorization and Billing Guidance
Provider Authorization and Billing Reference Guide
Medi-Cal Shared Risk Amendment Template
Physician Certification Statement (PCS) form

 

Additional Referral Forms

CA Pediatric WIC Referral Form
Referral for Potential Quality of Care Issues Form
Critical Incident (CI) Report Form