---
title: L.A. Care Health Plan ABA coverage (Medi-Cal).
url: "https://carelu.com/payers/la-care-health-plan-california"
markdown_url: "https://carelu.com/payers/la-care-health-plan-california.md"
state: CA (California)
payer: L.A. Care Health Plan (Medi-Cal)
kind: Medicaid managed care plan (MCO)
parent_program: Medi-Cal (California Medicaid)
description: "How L.A. Care Health Plan covers Medi-Cal Behavioral Health Treatment (ABA) in Los Angeles County — the in-house ASD Program, no autism diagnosis required, form LA5480 and its H-code grid (H0032 = assessment here), the 12-hour FBA cap, the mandatory reporting template, and how Plan Partner members differ."
last_reviewed: October 2026
---

# L.A. Care Health Plan ABA coverage (Medi-Cal).

_Payer Guide · L.A. Care Health Plan · Last updated October 2026 · 10 primary sources_

> Largest Medi-Cal plan (2.08M); BHT in-house via the ASD Program, H-codes on form LA5480, no autism dx required.

L.A. Care Health Plan is the Los Angeles County local initiative and the largest Medi-Cal plan in the state — 2,078,171 members in August 2026. For its directly enrolled Medi-Cal members, BHT is run in-house: "BHT services are provided through L.A. Care’s directly contracted BHT network," not through the member’s medical group and not through Carelon (which handles mild-to-moderate mental health for Medi-Cal and BHT only for L.A. Care’s commercial lines). L.A. Care also has two Medi-Cal Plan Partners — Anthem Blue Cross and Blue Shield of California Promise Health Plan — whose members may carry a different card; check which plan manages the child before submitting.

This plan administers the **Medi-Cal (California Medicaid)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Medi-Cal (California Medicaid) guide](https://carelu.com/payers/medi-cal-california-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — the FBA is requested on form LA5480 as "H0032 for initial ABA assessment ONLY," up to 12 hours (48 units); "Do not schedule services until authorization is obtained" [4]
- **Prior auth for treatment**: Required — BHT needs a "recommendation from a licensed physician or licensed psychologist, and prior authorization from L.A. Care"; direct service (H2019), supervision (H0031) and parent education (S5111) are requested as hours per month on LA5480, with reports on L.A. Care’s mandatory BHT reporting template [2][4][5]
- **Autism diagnosis required?**: No — "a diagnosis of autism or autism spectrum disorder is no longer required for children 0-21"; "A formal recommendation or prescription for ABA from a licensed psychologist or physician is a requirement" [6][4]

## At a glance

- **Plan type:** Local initiative, Two-Plan model (Los Angeles County); Plan Partners: Anthem Blue Cross, Blue Shield Promise
- **Who runs BHT:** L.A. Care’s own BH ASD Program (not the IPA, not Carelon) for direct Medi-Cal members
- **Diagnosis:** Not required — physician/surgeon/psychologist recommendation
- **Assessment auth:** Yes — H0032 on LA5480, up to 12 hours (48 units)
- **Codes:** HCPCS: H0032 assessment, H0031 supervision, H2019 direct, S5111 parent education, H2014 group
- **Submit via:** Fax LA5480 to (213) 438-5054; BHT line 1-888-347-2264; ASDbenefit@lacare.org

## How a BHT request works at L.A. Care

A PCP or family starts it: PCPs call 888-347-2264 or email ASDBenefit@lacare.org, or ask the "patient, parent, or caregiver to contact L.A. Care BHT team directly." The authorization form LA5480 (May 2026) says "All 4 criteria must be met for approval" — the member is under 21, has a licensed physician/surgeon/psychologist recommendation "with documentation demonstrating medical necessity," is medically stable with documentation, and needs no 24-hour or ICF-ID care. The functional behavior assessment is "H0032 for initial ABA assessment ONLY," up to "12hours total (48 units) across modifiers." Treatment is requested as hours per month: H2019 direct service (HN/HC/HP modifiers by tier), H0031-HP case supervision (with an optional second tier), S5111-HP for parent education programs, H2014 social skills group only if contracted. HN-level staff need a transcript and attestation. FBA, progress and closing reports must use L.A. Care’s mandatory BHT Reporting Template, which tracks the first appointment offered after FBA approval against a 10-day timeline. [4][6][5][2]

Watch the codes: L.A. Care uses H0032 for the assessment and H0031 for supervision — the reverse of IEHP and CalOptima. Never copy a code grid across plans. The form linked from L.A. Care’s BH Resources page (LA5480 10/25) is a dead link; use the 05/26 version from the Provider Manuals page. [4][6][5][2]

## Claims: filing limit, payment and provider disputes

L.A. Care’s 2026 Universal Provider Manual sets the Medi-Cal (MCLA) timely filing limit at "Within 180 calendar days from the date of service," with late claims denied unless the provider shows good cause, and secondary (COB) claims due within 180 calendar days of the primary’s determination. Clean claims are processed within 30 calendar days (DHCS and DMHC standard), which since January 1, 2026 is also the statutory deadline for Medi-Cal plans, with 15% annual interest from day 31 (AB 3275). Billing for services not authorized, or not on the authorization, "may result in a denial of the service and/or the entire claim," and authorizations are valid only if the member is eligible on the date of service. [1][2]

Provider disputes — "a written notice challenging, appealing or requesting reconsideration of a claim’s initial determination" — must be filed "within 365 calendar days of the health plan’s last action." L.A. Care acknowledges within 15 working days and sends a written determination within 45 business days for Medi-Cal. A second-level dispute goes to L.A. Care (P.O. Box 811610, Los Angeles, CA 90081) marked "Second Level Dispute"; once a dispute is upheld twice, the provider "is advised to seek relief with the DMHC." [1][2]

## Intake gates

The questions that decide whether a family can start with L.A. Care Health Plan (Medi-Cal), and what they have to bring.

- **Age limit**: Under 21 — "L.A. Care covers BHT for all Members under 21 years of age"; the PCP flyer says "0-21." No minimum age. [2][6]
- **Who may diagnose**: A licensed physician, surgeon or psychologist — the 2026 manual says "licensed physician or licensed psychologist" in one section and "licensed physician, surgeon, or psychologist" in the BHT chapter. [2][3]
- **Diagnostic tools required**: None required for the recommendation. For the FBA and progress reports the template asks for skills assessments "(e.g., VB-MAPP, Vineland, AFFLS, PEAK, etc.)," a preference assessment, and a functional or ABC analysis "Required for all target behaviors being addressed." [5]
- **Referral required?**: A PCP or the family can start it — PCPs call 888-347-2264 or email ASDBenefit@lacare.org, or have the "patient, parent, or caregiver … contact L.A. Care BHT team directly"; supporting documents (CDE, EPSDT results, recommendation) go by fax to 213-438-5054. BHT does not go through the member’s medical group or IPA. [6][2]
- **Prior-auth decision time**: L.A. Care’s 2026 manual counts days from receipt (day 0) but publishes numeric decision times only for its D-SNP line, so the state rule governs its Medi-Cal BHT requests: APL 21-011 — standard decisions within five business days of receiving the information reasonably necessary, never more than 14 calendar days, and 72 hours expedited — capped from January 1, 2026 at 7 calendar days by 42 CFR 438.210(d). Separately, L.A. Care tracks the provider’s first appointment offer within 10 days of FBA approval. Reauthorization: the treatment plan is reviewed at least every six months (APL 23-010). [2][12][13][5]
- **Other insurance (who pays first)**: When another payer is primary, "Providers must follow the primary payor’s billing rules"; secondary claims go to L.A. Care within 180 calendar days of the primary’s determination with its RA or denial, and L.A. Care pays cost-sharing "up to the lower amount of its fee schedule or the Medicare/other insurance-allowed amount." Medi-Cal is payer of last resort (APL 22-027). L.A. Care does not say whether its own BHT authorization is required when commercial insurance is primary — ask the BHT Department. [2][14]
- **Diagnosis recency** _(plan-dependent)_: L.A. Care publishes no age limit on the recommendation (checked LA5480, the reporting template and the 2026 manual), and APL 23-010 sets none. Its reporting template requires skills-assessment results "Updated results required annually" and preference assessments every six months. [5][8]
  - Ask the plan: L.A. Care BHT Department (1-888-347-2264 / ASDbenefit@lacare.org) — how recent the recommendation must be.
- **Telehealth** _(plan-dependent)_: No BHT-specific rule. L.A. Care’s general telehealth section requires a participating provider, disallows telehealth "when the Member and participating Provider are in the same physical location," and excludes "texting, facsimile or email only." Beyond that the Medi-Cal telehealth rule applies: modifier 95 for video, 93 for audio-only, GQ for store-and-forward, and POS 02 (outside the home) or 10 (in the home). That rule does not settle technician-delivered 97153/H2019 by video. [2][11]
  - Ask the plan: L.A. Care BHT Department (1-888-347-2264) — which BHT codes it will authorize by telehealth.

## Delivery and billing rules

Coverage decides whether L.A. Care Health Plan (Medi-Cal) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Daily limits / MUEs**: The only published cap is on the assessment: "up to 12hours total (48 units)." No daily or weekly treatment cap is published — treatment is requested as hours per month — and APL 23-010 prohibits hour caps. [4][8]
- **Session-note signature**: Reports (FBA, progress, closing) need a "Qualified Autism Service Provider Signature," credentials and date, plus a statement that the report "has been thoroughly discussed with client’s parent(s)" and the parent’s agreement or disagreement. No session-note rule is published. [5]
- **Place of service**: Treatment "is typically conducted in children’s homes for hours a day and in other community settings" (PCP flyer); the reporting template has school sections (IEP, coordination with the school) and a "Location(s) of Services" field. The state rule underneath (APL 23-010) covers home, clinic, community and school. [6][5][8]
- **Supervision** _(plan-dependent)_: Case supervision is authorized separately — H0031-HP required, with an optional second tier (HC for BCaBA/master’s, HN for bachelor’s). L.A. Care publishes no supervision ratio. [4]
  - Ask the plan: L.A. Care BHT Department or your BHT provider contract.
- **Bill as provider** _(plan-dependent)_: Rendering level rides on the modifier: HP (BCBA-D/BCBA/licensed master’s), HC (BCaBA or master’s), HN (bachelor’s), HQ (group). The form captures the requesting and servicing organization; no NPI or enrollment rule is published. [4]
  - Ask the plan: Your L.A. Care BHT contract — rendering vs. billing NPI for technician time.
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not published — no L.A. Care rule on billing supervision (H0031) and direct service (H2019) for the same clock time; note L.A. Care authorizes HCPCS codes, not 97153/97155. [4]
  - Ask the plan: Your L.A. Care BHT contract or Provider Solutions (866-522-2736).

## What intake should collect for L.A. Care Health Plan (Medi-Cal)

- **Which plan manages the child:** L.A. Care direct vs. a Plan Partner card (Anthem Blue Cross, Blue Shield Promise) — the BHT process differs.
- **Recommendation with documentation:** From a licensed physician, surgeon or psychologist, showing medical necessity — no autism diagnosis needed.
- **Medical stability note:** LA5480 requires documentation (e.g. a physician note) that the child is medically stable.
- **Staff credentials for HN tier:** Transcript and attestation for bachelor’s-level (HN) staff.
- **Other coverage:** Commercial insurance pays first; L.A. Care needs the primary’s RA or denial for secondary claims.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does L.A. Care cover ABA therapy?

Yes — as Behavioral Health Treatment for Medi-Cal members under 21. No autism diagnosis is needed; a licensed physician, surgeon or psychologist must recommend it, and L.A. Care must authorize it.

### How do I request ABA from L.A. Care?

Fax form LA5480 (05/26) with the recommendation and documentation to (213) 438-5054, or call the BHT team at 1-888-347-2264. The FBA is requested as H0032, up to 12 hours.

### Does the member’s medical group handle ABA?

No. For L.A. Care’s direct Medi-Cal members, BHT goes through L.A. Care’s own BHT network, not the IPA. Members on a Plan Partner card (Anthem Blue Cross, Blue Shield Promise) may follow that plan’s process.

### What happens when a family is switching providers or plans with L.A. Care?

State rule: APL 23-010 requires every Medi-Cal plan to offer continued access to out-of-network BHT providers (continuity of care) for up to 12 months under APL 23-022, so ask L.A. Care for a continuity-of-care arrangement before treatment stops. No state document says whether an existing authorization follows the child to a new agency within the plan; ask the plan before switching.

### What are L.A. Care’s ABA prior authorization and diagnostic requirements?

Fax form LA5480 (05/26) to (213) 438-5054. All four criteria must be met: the member is under 21; a licensed physician, surgeon or psychologist recommends BHT "with documentation demonstrating medical necessity"; the child is medically stable (e.g. a physician note); and no 24-hour or ICF/ID care is needed. No autism diagnosis is required, no instrument is required behind the recommendation, and L.A. Care publishes no recency window for it. The FBA is H0032, up to 12 hours (48 units); treatment is requested as hours per month on H2019, H0031 and S5111. Decisions follow the state clock — five business days, 72 hours urgent, never more than 7 calendar days from 2026.

### What is L.A. Care’s timely filing limit for Medi-Cal ABA claims?

Within 180 calendar days from the date of service for Medi-Cal (MCLA) claims, per the 2026 Universal Provider Manual. Clean claims are processed within 30 calendar days, and provider disputes are due within 365 calendar days of L.A. Care’s last action.

## Primary sources

1. [AB 3275 (Ch. 763, Stats. 2024) — claim reimbursement within 30 calendar days from 1/1/2026 (H&S § 1371, Ins. Code § 10123.13, W&I § 14093.08)](https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240AB3275)
2. [L.A. Care — 2026 Universal Provider Manual (LA4289)](https://www.lacare.org/sites/default/files/la4289_upm_202512.pdf)
3. [L.A. Care — 2026 Universal Provider Manual Errata v3 (9/23/2026)](https://www.lacare.org/sites/default/files/la8085_upm_errata_list_v3_20260923.pdf)
4. [L.A. Care — BHT/ABA Authorization Request Form LA5480 (05/26)](https://www.lacare.org/sites/default/files/la5480_bht_authorization_form_202605.pdf)
5. [L.A. Care — Behavioral Health Treatment Reporting Template (PL6030, 09/25)](https://www.lacare.org/sites/default/files/la6030_lac_bht_reporting_template_202509.pdf)
6. [L.A. Care — BHT Coverage for Members Under 21 (PCP flyer PL1757, 11/23)](https://www.lacare.org/sites/default/files/pl1757_bht_pcp_flyer_202311_0.pdf)
7. [L.A. Care — Behavioral Health Services (provider page)](https://www.lacare.org/providers/tools/behavioral-health-services)
8. [DHCS APL 23-010 (Revised 11/22/2023) — BHT Coverage for Members Under 21](https://www.dhcs.ca.gov/file/apl23-010-pdf/)
9. [CHHS Open Data — Medi-Cal Managed Care Enrollment Report (August 2026)](https://data.chhs.ca.gov/dataset/medi-cal-managed-care-enrollment-report)
10. [L.A. Care — thePULSE provider e-newsletter archive](https://lacare.org/providers/news/thepulse)
11. [Medi-Cal Provider Manual — Telehealth Modalities (tele mod), Nov 2025](https://mcweb.apps.prd.cammis.medi-cal.ca.gov/file/manual?fn=telemod.pdf)
12. [DHCS APL 21-011 (Revised 8/31/2022) — Grievance and Appeals Requirements](https://www.dhcs.ca.gov/file/apl21-011-pdf/)
13. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes](https://www.ecfr.gov/current/title-42/section-438.210)
14. [DHCS APL 22-027 — Cost Avoidance and Post-Payment Recovery for Other Health Coverage](https://www.dhcs.ca.gov/file/apl22-027-pdf/)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.