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11.0 Finance . . . . . . . . . . . . . . . . . . . . . . . . . 130Capitation Payments . . . . . . . . . . . . . . . . . . . . . . .Capitation Statement Report. . . . . . . . . . . . . . . . .Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Minimum Financial Solvency Standards. . . . . . . . .Reimbursement Services and Reports. . . . . . . . . . .Records, Reports, and Inspection. . . . . . . . . . . . . .13013013013113113212.0 Claims and Payment. . . . . . . . . . . . . 133Responsibility of Participating Providers. . . . . . . . .Claims Submission. . . . . . . . . . . . . . . . . . . . . . . . .Claims Adjudication. . . . . . . . . . . . . . . . . . . . . . . .Provider Portal Claims Verification. . . . . . . . . . . . .Coordination of Benefits . . . . . . . . . . . . . . . . . . . .Balance Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . .Provider Disputes. . . . . . . . . . . . . . . . . . . . . . . . . .Payment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Reporting: Quarterly Filing of AB1455. . . . . . . . .13313313313413413413413513613.0 Encounter Data. . . . . . . . . . . . . . . . . . 137Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13714.0 Marketing. . . . . . . . . . . . . . . . . . . . . . . 138Regulatory Approval. . . . . . . . . . . . . . . . . . . . . . . .Marketing Activities and Standards . . . . . . . . . . . .Approval Process . . . . . . . . . . . . . . . . . . . . . . . . . .Prohibited Activities. . . . . . . . . . . . . . . . . . . . . . . .13813813914015.0 Compliance . . . . . . . . . . . . . . . . . . . . . 141Goal and Objectives. . . . . . . . . . . . . . . . . . . . . . . .Authority and Responsibility. . . . . . . . . . . . . . . . .Delegation of Compliance and Audit Program. . . .Audit and Oversight Activities. . . . . . . . . . . . . . . .Provider Compliance Responsibilities. . . . . . . . . . .L.A. Care’s Program Integrity Plan. . . . . . . . . . . . .Enforcement of Disciplinary Standards . . . . . . . . .The Federal and California False Claims Acts. . . . .Health Insurance Portabilityand Accountability Act (HIPAA). . . . . . . . . . . . . .Privacy and Information SecurityRelated Resources and Websites. . . . . . . . . . . . . . .14114114114114214414614614614716. 0 Pharmacy. . . . . . . . . . . . . . . . . . . . . . . 148Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Pharmacy Quality andOversight Committee (PQOC). . . . . . . . . . . . . . .How to Use the Formulary. . . . . . . . . . . . . . . . . . .Generic Substitution . . . . . . . . . . . . . . . . . . . . . . .Non-Formulary Agents . . . . . . . . . . . . . . . . . . . . .Restrictions on Drug Coverage. . . . . . . . . . . . . . . .Prescription Drug PriorAuthorization Request Process. . . . . . . . . . . . . . . .Appeals and Grievances . . . . . . . . . . . . . . . . . . . . .Diabetes Testing Supplies. . . . . . . . . . . . . . . . . . . .Over-the-Counter Medication Coverage . . . . . . . .Devices & Vaccines . . . . . . . . . . . . . . . . . . . . . . . .General Benefit Exclusions (Not Covered). . . . . . .Pharmacy Network. . . . . . . . . . . . . . . . . . . . . . . . .Mail Order Prescriptions . . . . . . . . . . . . . . . . . . . .Specialty Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . .Pain Medication for the Terminally Ill. . . . . . . . . .Therapeutic Interchange. . . . . . . . . . . . . . . . . . . . .Opioid Utilization Monitoring. . . . . . . . . . . . . . . .E-Prescribing/Electronic Health Records . . . . . . . .Role of Navitus Health Solutions. . . . . . . . . . . . . .Contact Us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5115115115115117.0 Managed Long TermServices and Support . . . . . . . . . . . . . . . . 152Managed Long Term Services andSupports: A Resource for Providers. . . . . . . . . . . . .In-Home Supportive Services. . . . . . . . . . . . . . . . .Community Based Adult Services. . . . . . . . . . . . . .Multipurpose Senior Services Program. . . . . . . . . .Care Plan Options. . . . . . . . . . . . . . . . . . . . . . . . .Long Term Care. . . . . . . . . . . . . . . . . . . . . . . . . . .152152153153153154

1.0 Welcome ToL.A. Care Health Plan1.1 General IntroductionThank you for participating in L.A. Care Health Plan’s(L.A. Care) provider network and helping fulfill itsmission to provide high quality health care services toL.A. Care’s members in Los Angeles County.We would like to welcome you to L.A. Care. As partof L.A. Care’s Medi-Cal Direct (MCLA) networkof providers; you play a very important role in thedelivery of health care services to our members.The purpose of this L.A. Care Medi-Cal ProviderManual (Provider Manual) is to furnish all Providers,including Participating Physician Groups (PPGs) andtheir affiliated Provider networks, specialty healthplans, physicians or physician groups, hospitals, safetynet providers, California Community-Based AdultServices (CBAS) centers, and other ancillary providers,with information on the important processes relatedto L.A. Care’s Medi-Cal product. The ProviderManual is organized by substantive sections andprovides information about applicable requirementsfor the Medi-Cal program, L.A. Care policies, generalreference information, including minimum standardsof care, and other responsibilities. Please read eachsection in this Provider Manual carefully in order todetermine your contracted provider responsibilities.1.1.1 Medi-Cal and the Two Plan ModelMedi-Cal is California’s Medicaid program. It is apublic health insurance program administered bythe California Department of Health Care Services(DHCS). The Medi-Cal program was establishedin 1965 to provide the necessary health services forlow-income individuals or people with disabilities. InCalifornia, the Medi-Cal program is governed by theCalifornia Welfare and Institutions Code and provisionsof Title 22 of the California Code of Regulations. Since1998, significant portions of the Medi-Cal populationhave been enrolled into managed care organizationson a mandatory basis. In 2014, as a result of theimplementation of Affordable Care Act, Medi-Calmanaged care enrollment expanded. In Los AngelesCounty, Medi-Cal is operated through a Two-PlanModel consisting of a “local initiative” health planand a commercial plan. L.A. Care is the local initiativemanaged care plan in Los Angeles County. Currently,Health Net is the commercial plan.61.1.2 Responsibility ofParticipating ProvidersL.A. Care requires that its contracted Providers(including but not limited to medical groups, hospitals,Providers, PPGs, specialized health plans, physiciansor physician groups, hospitals, community-basedadult services (CBAS) centers, and other ancillaryProviders) meet specific requirements. Many sectionsof this Provider Manual include a section entitled“Responsibility of Participating Providers.” This sectionis provided to assist the contracted Provider withunderstanding which functions are the responsibility ofL.A. Care, PPGs, hospitals, ancillary Providers, and/orother participating Providers, respectively.1.1.3 L.A. Care’s Commitmentto Prvide Excellent ServicesL.A. Care’s overall goal is to develop policies,procedures, and guidelines for effectiveimplementation of Provider services in its productlines. To accomplish this goal, L.A. Care will workcooperatively with network Providers to ensurethat they have timely access to information and theappropriate resources to meet service requirements.1.1.4 Traditional and SafetyNet ProvidersL.A. Care considers the following provider types assome examples, but not all inclusive examples ofTraditional or Safety Net Providers: Child Healthand Disability Prevention (CHDP) Providers,Federally Qualified Health Centers (FQHCs),licensed community clinics, and DisproportionateShare Hospitals.1.2 Website InformationAvailable to ProvidersThe L.A. Care website has useful information forProviders. Please visit our website at www.lacare.orgfor information about the following: Provider Portal Sign In Check Patient Eligibility PCP Registration Provider Resources Cal MediConnect Tools Provider Manuals Provider Forms Utilization Management Forms Pre-Authorization Request Form

Hospital Authorization and Billing ReferenceGuide Care Management Forms Care Management Referral Form Claims Forms PM-160 Form CMS 1500 Claim Form Provider Dispute Resolution Request Form Managed Long Term Services and Supports Long Term Care and CBAS Referral RequestForm LTSS Referral Form Prescription Drug Prior Authorization RequestForm Medicare (Cal MediConnect) CoverageDetermination Form Prior Authorization Request Forms Reference Guide Coding Reference Guide for Acute RespiratoryConditions Provider Authorization and Billing ReferenceGuide SNF Authorization and Billing Guidance Provider Portal Resources Provider Portal Reference Guide Additional Referral Forms CA Pediatric WIC Referral Form Provider Policies Provider Toolkits Staying Healthy Forms Clinical Guidelines Skilled Nursing Resources Health Advisories Progress Notes The PULSE Newsletter Sign Up Claims and ICD-10 Submitting a Claim ICD-10 Provider Training Classes & Seminars Physician Leadership ProgramIf you would like paper copies of any of the informationavailable on the website, please contact us at1.866.LA.CARE6 (1.866.522.2736) and submityour request.1.3 Notice to ProvidersFrom time to time, L.A. Care amends Providercontracts and updates the Provider Manual and/or its Policies and Procedures. Updates are doneto ensure Providers have necessary information onthe most up-to-date laws, regulations, and revisionsto provide the highest quality services to L.A. CareMembers and ensure regulatory compliance. L.A. Careworks to promptly notify all Providers of materialchanges in requirements. L.A. Care utilizes multiplecommunication avenues to advise providers of changese.g. newsletters, e-mails, letters, and announcementson our website. For more information, please refer tothe L.A. Care’s website located at www.lacare.org. Behavioral Health Behavioral Health Services Forms and Toolkits Specialty Mental Health Substance Use Disorder Pharmacy Services Medication Adherence Prior Authorizations List of Covered Drugs HEDIS Resources Health Education Tools Social Services Directory Quality Improvement Program Provider FAQs Provider News7

1.4 L.A. Care Departmental Contact ListL.A. Care Health Plan1055 W. 7th StreetLos Angeles, CA 900171.213.694.1250DepartmentContact InformationCapitation1.213.694.1250, x 4377Care Management1.844.200.0104Claims1.866.522.2736Mail L.A. Care claims questions to:L.A. Care Health PlanAttn: Claims Dept.P.O. Box 811580Los Angeles, CA 90081Cultural and Linguistic Services1.213.694.1250, x 4523Eligibility Verification,Provider Service LineRegister for the Provider Portal to verify member eligibility at:lacare.org and click on Provider Sign in.1.866.522.2736 or 1.866.LACARE6Encounter DataProvider Service Line;1.866.LA.CARE6 or 1.866.522.2736Health Education;Health in Motion1.855.856.6943Managed Long TermServices and Supports (MLTSS)Provider Inquiry Line:1.855.427.1223Fax: .694.1250, x 5712Member ServicesGeneral Information LineMedi-Cal – 888.839.9909CMC – 1.888.522.1298Pharmacy1.877.795.2227Prior Authorizations andHospital AdmissionsL.A. Care UM Department must be notified within 24 hoursor the next business day following inpatient admission.To submit an Authorization request:Call Toll-Free: 1.877.431.2273Fax: 1.213.623.8669Written Requests:L.A. Care Health Plan1055 W. 7th Street, 10th FloorLos Angeles, CA 90017Attn.: Utilization Management/Authorizations8

DepartmentContact InformationProvider Credentialing, Performance,and Certification1.844.530.7596Provider Information/Data IssuesProvider Inquiry Line1.866.LA.CARE6 or 1.866.522.2736Provider NetworkManagement1.213.694.1250, extension 4719Provider InquiriesProviders may communicate questions or concerns totheir contracted PPG or to L.A. Care directly.Telephone:L.A. Care’s Provider Services Unit:1.866.LACARE6,(1.866.522.2736)In writing:L.A. Care Health PlanAttn: Provider Relations1055 W. 7th Street, 10th FloorLos Angeles, CA. 90017E-mail:LACarePSU@lacare.org(Five to seven business-day turn-around response)Your assigned Provider Relations RepresentativeQuality Improvement, Senior Director1.213.694.1250, x 5744Quality Improvement, Medical Director1.213.694.1250, x 5315Quality Improvement,Disease Management1.213.694.1250, x 4768Quality Management, Director1.213.694.1250, x 5203Regulatory Affairs and Compliance1.213.694.1250, x 4292Utilization Management, Director1.213.694.1250, x 51819

Glossary of Terms10Acronym or Word(s)DefinitionAAPAmerican Academy of PediatricsAIMAccess for Infants and Mothers ProgramAncillary ServiceThe following services are considered ancillary: ambulance transportation;durable medical equipment (DME) including but not limited to apnea monitor,artificial limbs, and hearing aids; home health care; prosthetic and orthodonticdevices; and skilled nursing facilities.BOGBoard of GovernorsCAPCorrective Action PlansCBASCommunity Based Adult ServicesCCSCalifornia Children’s Services – This program provides health care services tochildren with certain physical limitations and diseases whose families cannotafford all or part of the care.CHDPChild Health & Disability PreventionCPSPComprehensive Perinatal Services ProgramsDDSDevelopmental Disability ServicesDHCSDepartment of Health Care ServicesDOFRDivision of Financial ResponsibilityFSRFacility Site ReviewHEDISHealthcare Effectiveness Data and Information SetIBNRIncurred But Not ReportedPASC-SEIUHome Care Workers Union

Acronym or Word(s)DefinitionIPAIndependent Practice Association – In the L.A. Care Provider Manual, IPA willbe referred to Participating Physician Groups (PPGs)L.A. CareL.A. Care Health Plan (Local Initiative Health Authority for Los Angeles County)LTCLong Term CareLTSSLong Term Services and Supports(a.k.a. Managed Long Term Supports and Services)MOUMemorandum of UnderstandingMLTSSManaged Long Term Services and Supports(a.k.a. Long Term Services and Supports)MRMIBManaged Risk Medical Insurance BoardMSSPMultipurpose Senior Services ProgramNCQANational Committee for Quality AssuranceNALNurse Advice LinePCPPrimary Care ProviderPNMProvider Network ManagementQIPQuality Improvement PlanSEDSeverely Emotionally DisturbedSNFSkilled Nursing FacilityWIC ProgramWomen, Infant & Children’s Nutritional Supplemental Program11

2.0 Membership andMembership ServicesThis section covers L.A. Care Medi-Cal membershipand Member Services. Topics include eligibility,enrollment and disenrollment, Primary Care Physician(PCP) assignment, complaint resolution, and memberrights and responsibilities.2.1 Responsibility ofParticipating ProvidersL.A. Care Medi-Cal participating Providers areresponsible for adhering to the Member Servicesprovisions and guidelines specified in this section.2.3 Member Enrollment, Assignment,and DisenrollmentL.A. Care informs Members about their enrollmentrights, responsibilities, plan benefits and rules.L.A. Care uses multiple methods to meet thecultural and linguistic needs of Members as well asto communicate with them in their own language,including, but not limited to, the following:DHCS basic Medi-Cal eligibility criteria include thefollowing categories: Translation of Member materials into thresholdlanguages Referral to physicians who can provide services inthe Member’s preferred language Use of qualified bilingual staff contracts fortelephonic and face-to-face interpreting services,including American Sign Language (ASL) at medicaland non-medical points of contact Hearing or speech impaired members cancontact L.A. Care through the CaliforniaTelecommunications Relay Services at TTY 711 Children under 21 years old Adults over 65 years old Low-income adults Families with children Individuals with disabilities Foster youth up to age 26 Pregnant womenL.A. Care publishes access information for Peoplewith Disabilities for each contracted Provider in theL.A. Care Provider Directories, which is updatedmonthly. Updated Provider Directories are sent to newMembers upon enrollment with the “New MemberWelcome Kit” and then annually thereafter, based onMember eligibility.In addition, Medi-Cal applicants must meet incomeand asset levels, as established by the Medi-Cal program.Providers should notify L.A. Care immediately of changesto their language capabilities and access information.All beneficiaries who are determined eligible for theMedi-Cal program may enroll into L.A. Care’s Medi-Calproduct line. For further information, go to the DHCS’site at http://www.dhcs.ca.gov/ or Covered California’ssite at http://www.coveredca.com/medi-cal/.2.3.1 Medi-Cal GuidelinesThere are two types of Medi-Cal programs in Los AngelesCounty, i.e. “fee-for-service” an

L.A. Care Health Plan 1.1 General Introduction Thank you for participating in L .A . Care Health Plan's (L .A . Care) provider network and helping fulfill its mission to provide high quality health care services to L .A . Care's members in Los Angeles County . We would like to welcome you to L .A . Care . As part of L .A .