What types of policy changes does L.A. Care Health Plan issue?

L.A. Care Health Plan regularly publishes coverage updates including prior authorization requirement changes, billing code additions or deletions, plan-type coverage modifications, and clinical policy revisions. PolicyChanges.app monitors these notices and summarizes the impact for providers.

How often does L.A. Care Health Plan update its policies?

L.A. Care Health Plan typically releases policy bulletins on a rolling basis throughout the year. Our system checks for new updates daily and adds them to this feed as soon as they are identified.

How many L.A. Care Health Plan policy changes are tracked here?

This page currently tracks 29 documented L.A. Care Health Plan policy changes. New items are added as they are identified.

What should I do when L.A. Care Health Plan changes a prior authorization policy?

Review each change's effective date and action-required notes. Update your billing and clinical workflows before the effective date to avoid claim denials. Each policy detail page on PolicyChanges.app includes a plain-English summary and action items.

PAYER POLICY CHANGES

L.A. Care Health Plan Policy Changes & Prior Auth Updates

We track 29 documented policy changes from L.A. Care Health Plan across CA. Each entry includes an AI-generated plain-English summary, effective date, affected billing codes, and a direct link to the original L.A. Care Health Plan notice. Use the related links below to narrow results by specialty or state, or create a free alert to get new L.A. Care Health Plan updates by email (daily or weekly, your choice, on every plan).

L.A. Care Health Plan · Effective Jan 1, 2027High impact
Unsatisfactory Immigration Status (UIS) Member Transition to Full Scope Medi-Cal Fee-for-Service
Effective January 1, 2027, L.A. Care Health Plan members with unsatisfactory immigration status (UIS) will transition from L.A. Care managed care to California Medi-Cal Fee-for-Service (FFS). Providers must complete transition planning and care coordination by December 31, 2026, and enroll in Medi-Cal FFS by January 1, 2027 to continue serving these members. Enhanced Care Management, CICM, Community Supports, Complex Care Management, and Transitional Care Services will end for transitioned members, but Community Health Worker services will continue in Medi-Cal FFS.
L.A. Care Health Plan · Effective Jan 1, 2027High impact
Unsatisfactory Immigration Status (UIS) Member Transition
Effective January 1, 2027, L.A. Care Health Plan members with Unsatisfactory Immigration Status (UIS) will transition from Medi-Cal managed care to Medi-Cal Fee-for-Service (FFS). Providers must be enrolled in Medi-Cal FFS through PAVE by January 1, 2027 to continue serving these patients and receive reimbursement. Billing workflows must shift from managed care to FFS processes, and providers should familiarize themselves with FFS billing requirements, rates, and newly available care management billing codes.
L.A. Care Health Plan · Effective Oct 28, 2026High impact
Updated HCPCS Codes Requiring Prior Authorization – Medicare
L.A. Care Health Plan now requires prior authorization for eight HCPCS codes for its Medicare members, following CMS's addition of those codes to the DMEPOS Required Prior Authorization List, effective October 28, 2026. Separately, 22 HCPCS codes were added to the Required Face-to-Face Encounter and Written Order Prior to Delivery list effective the same date, requiring a documented face-to-face encounter within six months before the written order and communication of the order to the supplier before delivery.
L.A. Care Health Plan · Effective Sep 25, 2026High impact
Inpatient Services, Prior Authorization (PA) Submission Reminders & Short-Term Post Hospitalization Housing (STPHH)
L.A. Care clarifies that routine vaginal and cesarean deliveries with standard postpartum stays (48-96 hours) do NOT require prior authorization, but any additional maternal or newborn services (NICU, complications, extended stays) DO require prior authorization with clear identification of the specific service and clinical diagnosis. Additionally, L.A. Care will stop accepting STPHH authorization requests after December 1, 2026, as this program sunsets effective January 1, 2027.
L.A. Care Health Plan · Effective Jun 17, 2026High impact
Maternal Mental Health Screening Requirements
L.A. Care revised its Maternal Mental Health Screening Requirements (effective immediately) requiring providers to conduct and document maternal mental health screenings during pregnancy (first trimester recommended) and within 6 weeks postpartum using validated tools (EPDS, PHQ-2, PHQ-9, PHQ-A), with positive screens requiring documented follow-up within 30 days. Billing teams must now use specific LOINC codes and ensure screening documentation is linked to billable CPT codes for proper claims submission and HEDIS measure reporting.
L.A. Care Health Plan · Effective Jun 2, 2026High impact
Maternal Mental Health Screening Requirement Update
L.A. Care Health Plan requires providers to conduct and document maternal mental health screenings during pregnancy and postpartum using validated tools like EPDS or PHQ-9, with specific billing codes for enhanced HEDIS reporting. Positive screens must have documented follow-up within 30 days and appropriate referrals within 10 days.
L.A. Care Health Plan · Effective Apr 28, 2026High impact
Complete Hospital Admission Notification & Authorization Request Submissions
L.A. Care Health Plan now requires hospitals to submit complete clinical documentation (H&P, ED notes, progress notes, lab results, etc.) along with the admission face sheet for all inpatient authorization requests. Face sheets alone will no longer be processed, and incomplete submissions will cause delays or denials.
L.A. Care Health Plan · Effective Jan 1, 2026High impact
Modernizing Prior Authorization and Interoperability Requirements Effective 2026–2027
L.A. Care Health Plan is implementing major prior authorization and interoperability changes in two phases: 2026 requirements include faster PA decision timeframes (7 days standard, 72 hours expedited), enhanced denial transparency, and public reporting of PA metrics. 2027 requirements mandate FHIR-based electronic PA APIs and real-time decision capabilities with 80% automation goals.
L.A. Care Health Plan · Identified Jun 20, 2026High impact
Provider Payment Reductions and Billing Guidelines
L.A. Care Health Plan implemented a 1% automatic payment reduction on claims per state mandate, with exemptions for certain services including family planning and services under the new TRI Fee Schedule. Provider Administered Drugs (PADs) billing requirements changed - they must now be verified against specific drug lists to determine if they should be billed as pharmacy or medical claims.
L.A. Care Health Plan · Effective Aug 3, 2026Medium impact
Available Resources and Reminders
L.A. Care Health Plan issued a reminder policy emphasizing Enhanced Care Management (ECM) eligibility screening and prior authorization best practices for L.A. Care members. The policy clarifies that DME prior authorization requests should originate from contracted DME suppliers (not ordering providers) to ensure accurate codes and quantities, and introduces in-home assessments via Periscope for complex DME requests exceeding $5,000 or with access concerns.
L.A. Care Health Plan · Effective Feb 27, 2026Medium impact
Let’s Keep Claims Moving – Helpful Billing Reminders
L.A. Care Health Plan issued billing reminders emphasizing that authorization details must exactly match claim submissions, including provider NPIs, service dates, CPT/HCPCS codes, and quantities. They also highlighted issues with improper data entry in claim form fields that interfere with automated processing.
L.A. Care Health Plan · Effective Oct 14, 2025Medium impact
Qtr 4 Direct Network Regional JOM - Central
L.A. Care Health Plan is requiring all Direct Network providers in the Central region to attend mandatory quarterly Joint Operations Meetings (JOMs) on October 14, 2025. The meeting covers performance metrics, incentive programs, and clinical initiatives, with presentations on closing gaps in care and behavioral health services.
L.A. Care Health Plan · Identified Oct 23, 2026Medium impact
Preventive Care Connections #4: Supporting Positive Billing Experiences
L.A. Care Health Plan issued a reminder (not a new policy change) reinforcing existing balance-billing protections and member cost-sharing compliance requirements. The guidance clarifies provider billing responsibilities, prohibits balance billing for denied or delayed claims, and outlines correction procedures if members are charged in error. This is an informational reinforcement of applicable law and existing contractual obligations, not a substantive policy modification.
L.A. Care Health Plan · Identified Oct 10, 2026Medium impact
Preventive Care Connections #4: Supporting Positive Billing Experiences
L.A. Care Health Plan issued a reminder to contracted providers reinforcing balance-billing protections and proper billing practices. Providers must bill the plan (not members) for covered services, collect only authorized cost-sharing, verify eligibility and benefits before requesting member payment, and promptly correct and refund any improper charges. This is a compliance reminder with no new policy changes, effective dates, or deadline.
L.A. Care Health Plan · Identified Oct 6, 2026Medium impact
Provider Payment Reductions and Billing Guidelines
This is historical material (published February 2025, discovered October 2026) from L.A. Care Health Plan describing already-effective payment policies: a 1% payment reduction mandated by California Welfare and Institutions Code 14105.191 (with exemptions for certain service types), implementation of Targeted Rate Increases (TRI) under the 2023 Budget Act and AB 118, and billing guidelines for Provider Administered Drugs (PADs). The billing team should verify current applicability with L.A. Care, as these policies may have been updated since publication.
L.A. Care Health Plan · Identified Oct 6, 2026Medium impact
Advance Notice - CMS Medicare Advantage Risk Adjustment Data Validation Audit
L.A. Care Health Plan has been selected for a CMS Medicare Advantage Risk Adjustment Data Validation (RADV) audit for Payment Year 2024. Providers may receive formal medical record requests from Wakely Consulting Group for encounters from January 1–December 31, 2023, and must submit complete records within 15 days of request receipt, including documentation of member, encounter, diagnoses, assessment, treatment, and provider authentication.
L.A. Care Health Plan · Identified Sep 22, 2026Medium impact
Remittance Advice (RA) Now Available on the Provider Portal
L.A. Care Health Plan has launched a new Provider Portal feature enabling providers to access, view, download, and print Remittance Advices (RAs) in a centralized location. Providers can search, filter, and sort RAs by check number or amount, and access RAs directly from claim details. Note: 835 EDI files remain available only through existing clearinghouses like PaySpan; this Portal feature is separate from PaySpan Health enrollment.
L.A. Care Health Plan · Identified Sep 10, 2026Medium impact
Preventive Care Connections - Transportation
L.A. Care Health Plan has launched a new transportation benefits program for Medi-Cal members, offering Non-Medical Transportation (NMT) for ambulatory patients and Non-Emergency Medical Transportation (NEMT) for patients with medical/physical conditions preventing safe use of standard transportation. NEMT requires a Physician Certification Statement (PCS) form submitted within 24 hours. This is an informational policy explaining existing benefits and provider/member resources; it does not establish new billing codes or change reimbursement.
L.A. Care Health Plan · Identified Jun 20, 2026Medium impact
Behavioral Health Treatment (BHT) – Applied Behavioral Analysis (ABA) Authorization Request Form
L.A. Care has updated their Behavioral Health Treatment (BHT) Applied Behavioral Analysis (ABA) authorization request form for members under 21. The form requires prior authorization for ABA services including diagnostic evaluations, functional behavioral assessments, and continuity of care services, with specific eligibility criteria and documentation requirements.
L.A. Care Health Plan · Identified Jun 20, 2026Medium impact
Initial Health Appointment (IHA) for Newly Enrolled Medi-Cal Members
Medi-Cal members enrolled through the L.A. Care Direct Network must complete an Initial Health Appointment (IHA) in a primary care setting within 120 days of enrollment. The IHA can be completed over one or multiple visits and must be provided in a manner culturally and linguistically appropriate for the member. The letter states that the updated APL 22-030 removed the IHEBA/Staying Healthy Assessment requirement, but appropriate risk assessments and screenings should still be completed and documented. This is from a May 21, 2024 letter, so check current applicability with L.A. Care before applying it.
L.A. Care Health Plan · Identified Jun 20, 2026Medium impact
Clarification on Submitted Corrected Claims
L.A. Care Health Plan has clarified requirements for submitting corrected claims, specifying that providers must include the exact L.A. Care claim number (including suffixes like A1) and use specific billing codes and forms. Corrected claims must be submitted within 365 days of initial determination and include all previously billed line items.
L.A. Care Health Plan · Identified Jun 20, 2026Medium impact
Clinical Care & Patient Experience Initiatives for 2024
L.A. Care runs member outreach programs, provider incentive and resource programs, and provider education under its L.A. Care Covered, Medi-Cal, D-SNP and PASC lines of business. The dated initiatives carry 2024 launch dates, which have now passed, so confirm current applicability before acting on any of them. A memo to PPGs with an August 2024 launch date states that no prior authorization is needed for obstetrical care, breast cancer screenings and cervical cancer screenings.
L.A. Care Health Plan · Identified Jun 20, 2026Medium impact
Targeted Rate Increases (TRI)
L.A. Care Health Plan has announced targeted rate increases (TRI) for certain services. This policy appears to be specific to L.A. Care members and involves reimbursement rate adjustments, though specific details about which services or the percentage increases are not available in the summary.
L.A. Care Health Plan · Identified Jun 20, 2026Medium impact
How to Access the L.A. Care Health Plan (L.A. Care) New Provider Portal
L.A. Care Health Plan is launching a new Provider Portal with enhanced features including real-time status tracking for Service Authorization Requests and claims. Providers will need to register through their Provider Portal Administrator or Provider Network Account Manager to access the new system.
L.A. Care Health Plan · Identified Jun 20, 2026Medium impact
L.A. Care Removes the Prior Authorization Requirement for Long Term Care (LTC) Service Codes (An)
L.A. Care Health Plan has eliminated the prior authorization requirement for Long Term Care (LTC) service codes. This means billing teams can now submit LTC claims directly without obtaining prior approval, streamlining the billing process for these services.
L.A. Care Health Plan · Identified Jun 20, 2026Medium impact
2026 Annual Training Initial Health Appointments (IHAs) Presentation
Direct Network providers must complete each member's Initial Health Appointment (IHA) within 120 calendar days of enrollment, perform it in the primary care setting in a culturally and linguistically appropriate way, and document it in the member's medical record. For members under 18 months, an IHA must include a history of the member's physical and mental health, an identification of risks, an assessment of need for preventive screens or services, health education, and the diagnosis and plan for treatment of any diseases. Members under 21 also require EPSDT screenings, and age-appropriate IHAs must include a completed blood lead screening or documented evidence of refusal.
L.A. Care Health Plan · Identified Jun 20, 2026Medium impact
Clinical Connections 2026
Providers should use the Provider Portal as the primary method for authorization requests and status updates, and use the UM Call Center at 877-431-2273 (Option 3, then Option 2, Monday to Friday, 8:00 AM to 5:00 PM) for clinical discussions such as acute inpatient stays and discharge authorization. Recuperative Care is a Room and Board service for L.A. Care Medi-Cal (MCLA) and D-SNP members, and Room and Board services are capped at 182 days per rolling 12-month period. Discharge orders for members leaving long-term care must be faxed for DME, home health, transportation and specialty follow-up at least 7 to 10 days before the planned discharge.
L.A. Care Health Plan · Identified Jun 20, 2026Low impact
Health Information Exchange (HIE) Adoption Incentive Program for Skilled Nursing Facilities (SNFs)
L.A. Care offered a fixed $7,000.00 Health Information Exchange (HIE) Adoption Incentive to contracted hospitals and acute care facilities in Los Angeles County that join the California Health and Human Services Agency Data Exchange Framework and an HIE, either LANES or Collective Medical Technology (CMT)/PointClickCare (PCC). Recipients must complete three milestones within the 12-month incentive term: sign the Data Sharing Agreement with CalHHS, finalize the Business Associate and Participation Agreement with LANES or CMT/PCC, and exchange Admission, Discharge and Transfer (ADT) and Continuity of Care Documents (CCDs). The incentive may only be used for first-year subscription costs and set-up costs for onboarding. L.A. Care may recoup all or part of the incentive from future capitation or claim payments. This is from a 2024 request for applications, so check current applicability with L.A. Care before acting.
L.A. Care Health Plan · Identified Jun 20, 2026Low impact
Care Management & Enhanced Care Management -Transitional Care Services
L.A. Care Health Plan has updated their Care Management, Enhanced Care Management, and Transitional Care Services programs for Direct Network patients. The policy provides contact information and referral processes for coordinating patient care, including post-discharge support within 30 days.

Payer news

Network, contract and program news from the payers we track.

L.A. Care Health Plan · Jul 29, 2026Payer news
Introducing Preventive Care Connections
L.A. Care Health Plan is launching Preventive Care Connections, a provider resource series to support primary care physicians in improving preventive care delivery and Annual Wellness Visit completion.
L.A. Care Health Plan · Jul 28, 2026Payer news
Introducing Preventive Care Connections
L.A. Care Health Plan is launching 'Preventive Care Connections,' a new provider resource series designed to support Primary Care Physicians in improving preventive care delivery and increasing Annual Wellness Visit completion.
L.A. Care Health Plan · Nov 3, 2025Payer news
Supporting Your Patients Impacted by CalFresh Interruption
L.A. Care is providing $5.4 million in emergency nutrition support due to federal government shutdown suspending CalFresh benefits. This is informational for providers to help direct patients to food assistance resources.
L.A. Care Health Plan · Jun 25, 2025Payer news
Medicaid Data Shared with the U.S. Department of Homeland Security and Immigration and Customs Enforcement
L.A. Care Health Plan notified providers that CMS may have shared Medicaid member data (including names, addresses, SSNs) with ICE on June 13, 2025.
L.A. Care Health Plan · Aug 26, 2024Payer news
IMPORTANT - New Address and Phone Number
L.A. Care Health Plan is relocating offices effective September 1, 2024. The new address is 1200 W. 7th Street, Los Angeles, CA 90017 and the new phone number is (213) 428-5500.

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Unsatisfactory Immigration Status (UIS) Member Transition to Full Scope Medi-Cal Fee-for-Service

Unsatisfactory Immigration Status (UIS) Member Transition

Updated HCPCS Codes Requiring Prior Authorization – Medicare

Inpatient Services, Prior Authorization (PA) Submission Reminders & Short-Term Post Hospitalization Housing (STPHH)

Maternal Mental Health Screening Requirements

Maternal Mental Health Screening Requirement Update

Complete Hospital Admission Notification & Authorization Request Submissions

Modernizing Prior Authorization and Interoperability Requirements Effective 2026–2027

Provider Payment Reductions and Billing Guidelines

Available Resources and Reminders

Let’s Keep Claims Moving – Helpful Billing Reminders

Qtr 4 Direct Network Regional JOM - Central

Preventive Care Connections #4: Supporting Positive Billing Experiences

Preventive Care Connections #4: Supporting Positive Billing Experiences

Provider Payment Reductions and Billing Guidelines

Advance Notice - CMS Medicare Advantage Risk Adjustment Data Validation Audit

Remittance Advice (RA) Now Available on the Provider Portal

Preventive Care Connections - Transportation

Behavioral Health Treatment (BHT) – Applied Behavioral Analysis (ABA) Authorization Request Form

Initial Health Appointment (IHA) for Newly Enrolled Medi-Cal Members

Clarification on Submitted Corrected Claims

Clinical Care & Patient Experience Initiatives for 2024

Targeted Rate Increases (TRI)

How to Access the L.A. Care Health Plan (L.A. Care) New Provider Portal

L.A. Care Removes the Prior Authorization Requirement for Long Term Care (LTC) Service Codes (An)

2026 Annual Training Initial Health Appointments (IHAs) Presentation

Clinical Connections 2026

Health Information Exchange (HIE) Adoption Incentive Program for Skilled Nursing Facilities (SNFs)

Care Management & Enhanced Care Management -Transitional Care Services

Payer news

Introducing Preventive Care Connections ↗

Introducing Preventive Care Connections ↗

Supporting Your Patients Impacted by CalFresh Interruption ↗

Medicaid Data Shared with the U.S. Department of Homeland Security and Immigration and Customs Enforcement ↗

IMPORTANT - New Address and Phone Number ↗

Introducing Preventive Care Connections

Introducing Preventive Care Connections

Supporting Your Patients Impacted by CalFresh Interruption

Medicaid Data Shared with the U.S. Department of Homeland Security and Immigration and Customs Enforcement

IMPORTANT - New Address and Phone Number