LA Care Health Plan is operated by the local public health authority in Los Angeles County. It opened its doors to low-income individuals, uninsured children and other vulnerable populations in 1997. LA Health Plan provides care to patients through several different “health coverage programs.” Medi-Cal is chief among those. LA Care Health Plan also operates a number of community resources centers in partnership with Blue Shield of California Promise Health Plan.

What Do Treatment Centers Working with LA Care Health Plan Need to Know About Utilization Forms, Utilization Management and Medical Necessity? 

Like most payers, LA Care Health Plan has a Utilization Management team (UM Team) that conducts prospective, concurrent and retrospective reviews of services rendered (or proposed services to be rendered) to members in an effort to keep costs “reasonable” and to limit medically unnecessary clinical interventions. 

LA Care Health Plan’s prospective utilization management reviews are cal “Pre-Authorizations” as in “Pre-Authorization of Residential Services.”

Examples of concurrent utilization management reviews at LA Care Health Plan include: 

• Authorization of MAT for children under 18 

• Authorization for specialty programs serving the unhoused 

• Pre-auths not received prior to admission 

• Re-auths for MAT for children under 18 

• Verification of ongoing medical necessary 

• Re-auths for residential treatment requests beyond the initial authorization period 

Utilization reviews and utilization forms are an important piece of addiction treatment billing and revenue cycle management .On the Behave Health blog, you’ll find that we often cover Utilization Review related topics for this reason. In the past we’ve talked about doing Utilization Reviews with Blue Cross Blue Shield of California and we’ve also shared our top Tips on How to Complete Utilization Reviews for Addiction Treatment Centers. URs are a huge component of good addiction treatment billing and revenue cycle management, as well as a key piece of the intake process, so it makes sense to spend time going over how to fine-tune the process and make it work for your organization. 

What Utilization Forms or Utilization Reviews are Needed for Addiction Treatment Centers Working with L.A. Care Health Plan? 

First, let’s clear up a common misconception about LA Care Health Plan. This payer does not directly cover residential or many other “more intensive” levels of addiction treatment care. Instead, LA Care Health Plan will spring for only basic screening and “brief interventions” with PCPs. For patients needing more care than can be provided at a simple doctor’s appointment, LA Care Health Plan will actually refer patients to Los Angeles County Substance Abuse Prevention and Control (SAPC), which will work with patients to cover more robust residential and non-residential treatment programs. Patients may also contact SAPC directly without a doctor’s referral.

You may find all the relevant forms, including the manual for SAPC providers, on the SAPC website. 

There, you’ll also find documentation on how eligibility verification works - also known as initial engagement authorization - for both residential and non-residential treatment with SAPC. 

Once you become a SAPC provider, you’ll have access to the Service Request Form, which will be the first authorization form you’ll need to complete for a client. Unfortunately, this form is not available online without becoming a provider first. 

How Do I Become an In-Network SAPC or LA Care Health Plan Addiction Treatment Provider?

Becoming in-network with SAPC and/or LA Care Health Plan is a fairly involved four-step process. 

1 - Register as a Vendor with LA County 

2 - Complete a Letter of Intent and send it to SAPC 

3 - Get the relevant licenses and certifications required of the type of facility you’re operating. Residential treatment facilities will also need to complete an ASAM level of care designation questionnaire. 

4 - Apply for a contract with SAPC. 

You can learn more about the process to becoming an in-network facility with SAPC on their 

“Interested in Becoming an SAPC Contracted Provider?” page. Before completing the process, it can be helpful to review the Los Angeles County DMC - ODS Drug Medi-Cal Organized Delivery System Provider Manual. 

Having Trouble With L.A. Care Plan Addiction Treatment Utilization Forms? We Can Help.

BehaveHealth’s Revenue Cycle Management (RCM) service includes soup-to-nuts, hyper-detailed, hands-on attention to every single component of your addiction treatment billing needs. We have strong working relationships with every major insurance company in the United States. 

Even better, we’re not health care generalists.  We only work for behavioral health providers like you.

Let our team of specialists handle it all: 

• Verification of Benefits 

• Utilization Review 

• Billing and Collections 

• Patient Responsibility

• Denials and Appeals 

Get your free trial started today and see why more addiction treatment centers prefer Behave Health.