Manuals and Forms

Universal Provider Manual

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L.A. Care offers its providers a Universal Provider Manual (UPM). The UPM serves to support our providers by helping you better understand our guidelines, policies and procedures, and to comply with applicable laws, rules, regulations, guidance, and accreditation standards.

Universal Provider Manual Effective 01/01/25

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

Behavioral Health Support Referral for Minors
BHT Authorization Form
BHT Reporting Template
BHT Parent Verification Receipt
Carelon Behavioral Health PCP Referral

Visit our Behavioral Health web page for program information.

Case Management Forms

Care Management Referral Form
ECM Benefit Member Referral Form - Adult
ECM Benefit Member Referral Form - Child and Youth

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

Employee Language Pre-Screening Tool

Health Education Forms

Health Education Referral Form
Medical Nutrition Therapy (MNT) Referral Form
Meals As Medicine SAR Form
Doula Benefit Provider Recommendation Form

Find more Health Education resources.

Initial Health Assessment Forms

Well Child Assessment Forms

Interpreter Poster

Order the 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 Community Supports (CS) Disenrollment Notification
MLTSS Referral Form
Nursing Facility Transition/Diversion Services: Service Authorization Request 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 and Formulary Forms

L.A. Care Medicare Plus (HMO-DSNP):
Quality Drug Clinical Care Form
Quality Drug Clinical Care Form (Spanish)

L.A. Care Covered/Direct & Homecare Workers Health Care Plan:

Postal Prescription Services Form
Postal Prescription Services 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
Hospital UM Related Fax Information for All L.A. Care Members
SNF Related Fax Information for All L.A. Care Members

Social Services Forms

Short Term Post-Hospitalization Service Authorization Request
Short Term Post Hospitalization Quick Reference Guide
Housing Navigation & Tenancy Services CS Service Authorization Request
Housing Navigation & Tenancy Services CS Quick Reference Guide
Day Habilitation CS Quick Reference Guide
Day Habilitation CS Service Authorization Request
Housing Navigation & Tenancy Services CS Service Reauthorization Request
Housing Deposits CS Quick Reference Guide
Housing Deposits CS Request for Funds Form
Recuperative Care Community Supports Program Quick Reference Guide
Recuperative Care Prior Authorization Request Form
Request for Recuperative Care Extension Form
Recuperative Care Provider Contracted Network
Community Health Worker Benefit Recommendation Form
Community Health Worker Benefit Assessment Form
Asthma Remediation Certificate of Completion
Asthma Remediation Service Authorization Request
Asthma Remediation Quick Reference Guide
Asthma Remediation Letter of Permission

For more program information, visit Community Supports.

Utilization Management Forms

Exception Request Form for Physicians
Provider Prior Authorization Tool
Prior Authorization Request Form
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)
Provider Authorization and Billing Reference Guide
Medi-Cal Shared Risk Amendment Template
Physician Certification Statement (PCS) form
L.A. Care Clinical Criteria Hierarchy
Emergency Department Protocols
BHT Authorization Form
Medicaid Attestation Form - Clinical Trial Services

Additional Referral Forms

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