L.A. Care Health Plan

• LC
• Medicaid MCO

L.A. Care Health Plan

Provider guide for L.A. Care Health Plan Medi-Cal MCO in Los Angeles County — credentialing, VOB, prior authorization, and billing for behavioral health.

Quick Reference

Payer Type

Medicaid MCO

Parent Company

Public nonprofit HMO (governed by a public board; independent of commercial insurers)

Headquarters

Los Angeles, CA

Provider Portal

Open Portal

Portal Guide

View Guide →

Credentialing

CAQH ProView plus California Medi-Cal enrollment (DHCS)

Timeline

90-120 days

Coverage

1 states

Last Verified

Apr 19, 2026

Published

Apr 19, 2026

Reading Time

11 min

Covered Levels of Care

• Medically Managed Detoxification
• Residential Treatment (via CA Drug Medi-Cal Organized Delivery System)
• Partial Hospitalization (PHP)
• Intensive Outpatient (IOP)
• Outpatient Treatment
• Crisis Stabilization
• Medication-Assisted Treatment (MAT)
• Peer Support and Recovery Services
• Mental Health Services Act (MHSA) enhanced services (for eligible members)

Medical Necessity Criteria

• California Medi-Cal Specialty Mental Health criteria (EPSDT / Medi-Cal guidelines)
• ASAM Criteria (for SUD level of care determinations)
• Drug Medi-Cal Organized Delivery System (DMC-ODS) clinical criteria

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Overview

L.A. Care Health Plan is the largest publicly operated health plan in the United States, headquartered in Los Angeles, California, and serving Medi-Cal managed care members in Los Angeles County. Established in 1997 under California law as a local initiative health plan, L.A. Care was created by the California Department of Health Services (now the Department of Health Care Services, or DHCS) specifically to provide a publicly accountable managed care option within the Los Angeles County Medi-Cal system. The plan is governed by a public Board of Governors that includes consumer advocates, safety-net hospital representatives, county health officials, community clinic representatives, and other stakeholders — giving it a governance structure that is meaningfully accountable to the communities it serves rather than to shareholders or parent corporation executives.

As of the mid-2020s, L.A. Care serves more than 2 million Medi-Cal members, making it the dominant Medicaid managed care plan in Los Angeles County by enrollment. The plan operates multiple Medi-Cal product lines, including L.A. Care Medi-Cal (the core product), L.A. Care Cal MediConnect (for Dual Eligible Special Needs Plan members eligible for both Medi-Cal and Medicare), and PASC-SEIU Homecare Workers Health Care Plan. L.A. Care also offers a Covered California marketplace plan. Its mission focus on low-income and underserved communities, including the nation’s largest Latino and uninsured populations, makes it a critical payer for safety-net behavioral health providers throughout Los Angeles County.

For behavioral health treatment providers, L.A. Care is the single most important Medicaid payer in the Los Angeles market. However, the California Medi-Cal behavioral health benefit structure is uniquely complex: specialty mental health services are carved out to the Los Angeles County Department of Mental Health (LACDMH) for members meeting clinical eligibility criteria, while substance use disorder services under the Drug Medi-Cal Organized Delivery System (DMC-ODS) are managed through a separate county-administered waiver program. Providers must understand which behavioral health benefits are managed by L.A. Care directly and which are carved out before beginning the network participation and credentialing process.

Behavioral Health Coverage

L.A. Care’s behavioral health coverage follows California’s Medi-Cal managed care framework, which divides behavioral health benefits into three distinct administrative systems: non-specialty mental health services managed by L.A. Care directly, specialty mental health services (SMHS) carved out to the Los Angeles County Department of Mental Health (LACDMH), and substance use disorder treatment services governed by the Drug Medi-Cal Organized Delivery System (DMC-ODS) administered by LA County’s Department of Public Health, Substance Abuse Prevention and Control (SAPC).

Non-specialty mental health services covered directly by L.A. Care include short-term outpatient therapy, psychiatric medication management for members who do not meet the SMHS threshold, crisis stabilization, and preventive mental health services. The SMHS benefit — which covers more intensive mental health services including residential mental health treatment, therapeutic behavioral services, full-service partnership programs, and intensive wraparound services — is the responsibility of LACDMH for qualifying members. Providers working with members who have complex mental health needs must determine whether the member’s clinical profile triggers the SMHS carve-out.

The Drug Medi-Cal Organized Delivery System (DMC-ODS) is a 1115 SUD waiver that Los Angeles County has fully implemented, and it significantly expands covered SUD services beyond what was available under legacy Drug Medi-Cal. DMC-ODS covered services in LA County include outpatient SUD treatment, intensive outpatient programs, residential treatment at ASAM 3.1 through 3.7 levels (for qualifying IMD-exempt facilities), clinically managed residential detoxification, medically monitored residential detoxification, medication-assisted treatment, and recovery support services. Providers seeking to deliver DMC-ODS SUD services must be certified by DHCS as a DMC-ODS provider, and billing flows through the county DMC-ODS system rather than directly through L.A. Care’s claims processing system for most SUD services.

The federal IMD exclusion — which historically barred Medicaid payment for services in facilities with more than 16 beds — is partially addressed in California through the 1115 waiver, but specific facility certification requirements and bed-size thresholds apply. Confirm your facility’s DMC-ODS certification level, IMD status, and the applicable waiver terms with DHCS and LA County SAPC before admitting L.A. Care members to residential SUD programs. Medication-assisted treatment, including buprenorphine, methadone, and naltrexone, is covered broadly under California’s Medi-Cal program in line with SUPPORT Act requirements.

Credentialing and Provider Enrollment

L.A. Care uses CAQH ProView as its primary credentialing data source for network participation. Before applying, ensure that all individual clinicians and your organization have fully attested CAQH ProView profiles reflecting current California licensure, National Provider Identifier (NPI) and taxonomy codes, professional liability coverage, and applicable facility certifications. For behavioral health facilities, this includes current California Department of Public Health (CDPH) or DHCS facility licensure and, for SUD programs, DHCS Drug Medi-Cal or DMC-ODS certification.

California Medi-Cal enrollment through the DHCS Provider Enrollment Division is an absolute prerequisite for joining the L.A. Care provider network. Enroll through the DHCS enrollment portal (Medi-Cal Provider Enrollment) before or concurrently with your L.A. Care network application. DHCS enrollment can take several weeks to months and may require facility site visits for residential and intensive outpatient programs. L.A. Care will not execute a provider agreement or begin processing claims until DHCS enrollment is active.

For providers seeking to deliver DMC-ODS SUD services, enrollment with LA County SAPC as a certified DMC-ODS provider is required in addition to DHCS enrollment and L.A. Care credentialing. The DMC-ODS provider enrollment and certification process is administered separately by SAPC and involves site visits, documentation review, and compliance with county DMC-ODS standards. This additional step can add months to the total onboarding timeline for SUD treatment providers.

Facility credentialing with L.A. Care requires current California behavioral health facility licensure, DHCS certification or DMC-ODS certification as applicable, organizational NPI, general and professional liability insurance at L.A. Care’s contracted minimum limits, Joint Commission or CARF accreditation if required for your level of care, and a current W-9. After a complete application is received, L.A. Care credentialing typically takes approximately 90 to 120 days. Recredentialing follows a standard three-year cycle.

Verification of Benefits (VOB)

Benefit verification for L.A. Care Medi-Cal members is a two-step process. First, confirm active California Medi-Cal enrollment and L.A. Care MCO assignment through the Medi-Cal eligibility verification system (MEVS) or the DHCS provider portal. You can also use standard HIPAA 270/271 electronic transactions through your clearinghouse. Confirm both that the member is enrolled in Medi-Cal and that L.A. Care is the assigned managed care plan on the date of service — Los Angeles County has multiple competing Medi-Cal managed care plans, and member assignments change.

Second, determine the benefit structure for the specific services you intend to provide. Given the carve-out architecture described above, you must identify whether the member’s behavioral health benefits for the requested service are managed by L.A. Care directly, carved out to LACDMH for specialty mental health, or subject to the DMC-ODS county SUD system. Contact L.A. Care provider services or use the provider portal at lacare.org/providers for benefits verification and to confirm authorization requirements. For SUD services, also contact LA County SAPC to confirm DMC-ODS eligibility and the applicable authorization pathway.

Medi-Cal eligibility can change monthly. Re-verify on or near each date of service. Because Medi-Cal is the payer of last resort, screen for commercial insurance, Medicare, TRICARE, or VA coverage that would take primary position. Document each VOB with date, representative name, reference number, the specific benefits confirmed, and any authorization requirements identified.

Prior Authorization Requirements

L.A. Care requires prior authorization for facility-based behavioral health services managed directly by the plan, including partial hospitalization programs and, when managed directly by L.A. Care rather than the DMC-ODS system, residential SUD treatment. Outpatient therapy and standard psychiatric medication management typically do not require prior authorization under the non-specialty mental health benefit. IOP authorization requirements should be confirmed in the current L.A. Care Provider Operations Manual, as California Medi-Cal managed care authorization rules have evolved with the state’s managed care and behavioral health integration reform agenda.

For DMC-ODS SUD services, prior authorization is managed through LA County SAPC rather than directly through L.A. Care. SAPC administers the DMC-ODS benefit and manages utilization review for residential, intensive outpatient, and other SUD services covered under the waiver. Submit authorization requests for DMC-ODS SUD services to SAPC using the county-defined authorization process and documentation requirements. Do not submit these to L.A. Care’s standard utilization management team, as the claim will also route through the county system.

For authorization requests submitted directly to L.A. Care, include comprehensive clinical documentation covering the member’s diagnoses, presenting symptoms, psychiatric and substance use history, current functional status, prior treatment episodes, and the proposed treatment plan. For SUD services within the L.A. Care direct benefit, document according to ASAM Criteria. For mental health services, follow California Medi-Cal clinical criteria and the EPSDT standard for members under age 21.

Concurrent reviews for residential and inpatient services are required at intervals published in the L.A. Care provider manual. Each review requires updated clinical documentation demonstrating progress toward treatment goals, continued medical necessity, and active discharge planning. If a continued-stay authorization is denied, request a peer-to-peer review before filing a formal appeal.

Claims and Billing

L.A. Care accepts electronic claims through standard EDI 837I (institutional, UB-04) and 837P (professional, CMS-1500) formats submitted via clearinghouses, and through the L.A. Care provider portal. Electronic submission is strongly preferred. Confirm the correct L.A. Care payer ID with your clearinghouse — L.A. Care uses separate payer IDs for different product lines (Medi-Cal, Cal MediConnect, and marketplace).

For DMC-ODS SUD services, claims billing follows the county SAPC billing process, which routes through the state’s Drug Medi-Cal billing system rather than through L.A. Care’s standard claims adjudication process. Confirm the correct billing pathway for each service type and each member before submitting claims. Billing SUD services to L.A. Care when they should be billed through SAPC’s DMC-ODS system is a leading cause of claim denials for SUD providers in Los Angeles County.

For non-specialty mental health and other services billed directly to L.A. Care, use California Medi-Cal billing codes and modifiers as required by the DHCS billing guidance and the L.A. Care provider contract. Timely filing for L.A. Care Medi-Cal claims follows California Medi-Cal MCO contract requirements — California generally requires initial claim submission within 90 days of the date of service, though provider agreement terms may vary. Reference the current L.A. Care Provider Operations Manual for the controlling deadline.

Common denial reasons include failure to submit through the correct billing system (L.A. Care vs. LACDMH vs. SAPC DMC-ODS), Medi-Cal ineligibility on the date of service, missing authorization, incorrect payer ID, non-covered service under the member’s specific benefit structure, and third-party liability issues. Track denial patterns and billing system routing errors carefully, as the multi-system architecture of California Medi-Cal behavioral health makes routing errors more common for providers new to the L.A. County market.

Key Contact Information

L.A. Care serves: Los Angeles County, California (Medi-Cal managed care)

• Provider Portal: https://www.lacare.org/providers ↗ (primary portal for L.A. Care network providers)
• Credentialing: CAQH ProView ( https://proview.caqh.org ↗ ) plus California Medi-Cal enrollment via DHCS; contact L.A. Care provider network development through the provider portal
• California Medi-Cal Enrollment: DHCS Provider Enrollment Division — dhcs.ca.gov/provgovpart/Pages/ProviderEnrollment.aspx
• DMC-ODS SUD Provider Enrollment: LA County SAPC — sapc.lacounty.gov (separate from L.A. Care credentialing)
• Specialty Mental Health Carve-Out: Los Angeles County Department of Mental Health (LACDMH) — dmh.lacounty.gov (for members meeting SMHS criteria)
• Prior Authorization: Submit through lacare.org/providers; DMC-ODS SUD authorization via LA County SAPC
• Verification of Benefits: MEVS for Medi-Cal enrollment + lacare.org/providers for plan benefits; call provider services for carve-out determination
• Claims Submission: Electronic 837I / 837P via clearinghouse to L.A. Care; DMC-ODS SUD claims via county SAPC billing system

Frequently Asked Questions

No. L.A. Care Health Plan is a fully independent public nonprofit health maintenance organization. It is not a subsidiary of any national insurance conglomerate. L.A. Care was created in 1997 by the California Department of Health Services (now DHCS) specifically to serve Medi-Cal managed care members in Los Angeles County and is governed by a public Board of Governors that includes consumer representatives, safety-net provider representatives, and county health officials. It is the largest publicly operated health plan in the United States. L.A. Care should not be confused with commercial carriers such as Anthem, Blue Shield of California, Kaiser, or Centene subsidiaries that also participate in Medi-Cal managed care in Los Angeles County.

The Drug Medi-Cal Organized Delivery System (DMC-ODS) is a California county-based Medicaid waiver program that expanded SUD treatment benefits, including residential treatment at ASAM 3.1 through 4.0 levels, withdrawal management, and intensive outpatient. Los Angeles County operates a DMC-ODS county plan, and L.A. Care members enrolled in the county's SUD benefit system access those services through the county DMC-ODS infrastructure, which may involve a separate authorization and billing pathway from L.A. Care's standard Medi-Cal managed care product. Providers must be certified by the California DHCS as a DMC-ODS provider and must work with the LA County Department of Public Health Substance Abuse Prevention and Control (SAPC) for the SUD services governed by the DMC-ODS waiver. Confirm the benefit structure for each member before providing and billing SUD services.

California Medi-Cal has historically used a specialty mental health carve-out system. The Los Angeles County Department of Mental Health (LACDMH) manages specialty mental health services for Medi-Cal members who meet criteria for the Specialty Mental Health Services (SMHS) benefit. L.A. Care and other Medi-Cal managed care plans cover non-specialty outpatient mental health services, but when a member's mental health needs reach the SMHS threshold, their care is carved out to LACDMH. This means that some behavioral health services for L.A. Care Medicaid members are billed through LACDMH rather than L.A. Care. Providers should screen each member's benefit structure to determine whether their mental health services fall under the L.A. Care benefit or the LACDMH carve-out.

L.A. Care uses CAQH ProView as its primary credentialing data source. Ensure your CAQH profile is fully attested and reflects your California state licensure, NPI, malpractice coverage, and any relevant facility certifications before initiating the L.A. Care network application. California Medi-Cal enrollment through the DHCS Provider Enrollment Division is a prerequisite — enroll via the DHCS enrollment portal before or concurrently with your L.A. Care application. For SUD treatment facilities, DHCS Drug Medi-Cal or DMC-ODS certification is required. The overall credentialing timeline is typically 90 to 120 days from receipt of a complete application. Contact L.A. Care provider services through lacare.org/providers for network application materials and current credentialing requirements.

Timely filing for L.A. Care Medi-Cal managed care claims follows California Medicaid managed care contract requirements. California Medi-Cal MCO contracts generally require initial claims to be submitted within 90 days of the date of service. However, your provider agreement with L.A. Care may specify a different window — in some cases up to 12 months for non-contracted providers or specific claim types. Corrected claims and coordination-of-benefits submissions have separate timely filing requirements. Reference the current L.A. Care Provider Operations Manual for the controlling deadline for your provider type and service category. Because late Medi-Cal claims have very limited recourse, build timely filing alerts into your billing system from the first day of service.

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