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Provider Payment Reductions and Billing Guidelines
Effective date
Not stated in the notice
Identified
Oct 6, 2026
Summary
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.
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What to do
Action · 11 steps
01HISTORICAL MATERIAL – No future deadline stated.
02Already effective policies described.
03The 1% payment reduction under W&I Code 14105.191 applies automatically in L.A.
04Care's claims system to all contracted services except free-standing sub-acute facilities, family planning services, free-standing pediatric sub-acute facilities, and services on the TRI Fee Schedule.
05Billing team should verify whether the practice is correctly classified and whether exemptions apply.
06For Provider Administered Drugs (PADs), billing team must verify current coverage status on the Contract Drugs List or Medi-Cal Rx Pharmacy Reimbursable Physician Administered Drugs list before submission; PADs not on these lists must be billed as medical claims and are subject to W&I 14105.191 reductions.
07Previous pharmacy network coverage (prior to January 1, 2022) does not guarantee current coverage.
08Contact L.A.
09Care Direct Network Account Manager or DirectNetwork@lacare.org for clarification on TRI Fee Schedule applicability or coverage verification.
10Because this policy was issued February 2025 and discovery occurred October 2026, confirm with L.A.
11Care whether any updates have superseded these guidelines.
Original notice
Provider Payment Reductions and Billing Guidelines
lacare.org · Always check the source before changing claims.